Asthma:
Symptoms, Stepwise Therapy and Everyday Life
At a glance
Affected
Worldwide ~260 million; 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/albuterol), biologics
ICD-10
J45
1. What is asthma?
Bronchial asthma is a chronic inflammatory disease of the airways. The bronchi react with hyperresponsiveness to various stimuli — generally producing three characteristic changes: the bronchial mucosa swells (inflammation), the bronchial muscles contract (bronchospasm), and viscous mucus is produced. The result: the airways narrow, and breathing out becomes particularly difficult.¹
Asthma often runs in attacks — phases with symptoms alternate with symptom-free intervals. Symptom intensity can change over the course of life and often fluctuates seasonally (e.g. pollen season, infection season).
New treatment goal: remission
Germany's National Disease Management Guideline on Asthma (NVL 2024) goes beyond mere symptom control — the aim is remission: as complete symptom freedom as possible on the lowest possible therapy. With modern medications, this goal is realistic for many people with asthma.¹
Form 1
Allergic asthma (extrinsic)
Triggered by allergens (e.g. pollen, house dust mites, animal dander, mold spores). Often begins in childhood. Frequently combined with hay fever and atopic dermatitis (atopic triad). Typically a type 2 inflammation with elevated IgE levels and eosinophil counts. In childhood, allergic asthma is the most common form.¹
Form 2
Non-allergic asthma (intrinsic)
No allergic component detectable. Often begins in adulthood. Typical triggers: respiratory infections (the most common trigger), cold air, physical exertion, environmental pollutants. Often more difficult to treat.
Form 3
Mixed forms & special forms
Very common — many patients have both allergic and non-allergic components.¹
- Aspirin-exacerbated respiratory disease (AERD): Triggered by NSAIDs such as aspirin/ASA or ibuprofen. Frequently combined with nasal polyps (Samter's triad). In known AERD, acetaminophen (paracetamol) can be an alternative.
- Exercise-induced asthma: Symptoms primarily with physical exertion — particularly in cold, dry air. Not a reason to give up sport.
3. Symptoms — and when it's an emergency
Typical asthma symptoms
- Episodic shortness of breath — particularly on exhalation (expiratory dyspnea)
- Wheezing — often audible on forced exhalation
- Dry, paroxysmal 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 viscous, glassy sputum
- Symptoms often worsen with allergen exposure, infections, physical exertion, cold air or stress
Typical for asthma: symptoms come and go
There are generally good and bad days or weeks. Seasonal fluctuations are common in allergic asthma.
Acute asthma attack — an emergency!
- Severe, increasing shortness of breath — exhalation is markedly prolonged
- Use of accessory respiratory muscles — bracing the arms, visible retraction of the skin between the ribs
- The person can no longer speak in long sentences
- Palpitations, anxiety, restlessness
- Bluish lips or fingernails (cyanosis) — a sign of oxygen deprivation
- No audible wheezing ("silent chest") — paradoxically a warning sign of very severe narrowing
What to do in a severe asthma attack
1) Stay calm. 2) Sit upright, brace your arms (tripod position). 3) Use your rescue inhaler per your personal action plan. 4) Pursed-lip breathing: exhale slowly through pursed lips. 5) If there's no improvement, with cyanosis or "silent chest," call emergency services (112 in the EU/UK, 911 in the US) immediately.¹
4. Causes and triggers
Why does asthma develop?
- Genetic predisposition — asthma, hay fever and atopic dermatitis often cluster in families¹
- Dysregulated immune response — an overreaction of the immune system to otherwise harmless stimuli (often a Th2-dominated inflammation)
- Environmental factors — e.g. air pollution, tobacco smoke (active and passive), particulate matter⁴
- Early-childhood factors — e.g. severe respiratory infections in infancy (including RSV)
- Overweight/obesity can raise the risk of asthma and impair control
What triggers asthma attacks?
- Allergens: pollen (seasonal), house dust mites (year-round), animal dander, mold spores
- Respiratory infections — a common trigger in non-allergic asthma and in children
- Physical exertion (exercise-induced asthma) — particularly in cold, dry air
- Cold air, fog, sudden weather changes
- Tobacco smoke, perfume, paints, cleaning agents, other chemicals
- Stress and psychological strain can favor asthma episodes
- NSAID painkillers (e.g. aspirin/ASA, ibuprofen) in aspirin-exacerbated respiratory disease
- Beta-blockers — can trigger bronchospasm in sensitive patients. Learn more: Medication interactions
5. Diagnosis
- Medical history: Typical symptoms (cough, shortness of breath, wheezing)? When, how often, what triggers? Family history? Coexisting allergies?
- Lung function test (spirometry): Measures lung volumes and flow rates (FEV1, FVC). Shows the typical obstructive ventilation pattern. A bronchodilator reversibility test can support the diagnosis.¹
- Peak flow measurement: Simple self-measurement at home. Diurnal variability can be a sign of asthma. Useful for follow-up and the asthma action plan (traffic-light scheme).
- FeNO measurement: Fractional exhaled nitric oxide — often elevated in eosinophilic type 2 inflammation. Can help guide treatment decisions.¹
- Allergy testing: Skin prick test, specific IgE in blood — when allergic asthma is suspected.
- Bronchial provocation test: e.g. with methacholine — when the diagnosis is unclear despite a normal lung function test.
- Differential diagnoses: COPD (particularly in smokers), vocal cord dysfunction, heart failure or reflux-related cough should be ruled out.
Learn more: Preparing for a doctor's appointment.
6. Medications: stepwise therapy per Germany's NVL 2024
Asthma therapy in Germany follows a 5-step scheme from the National Disease Management Guideline (NVL).¹ Core 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 in each case is always decided by your treating doctor. (Internationally, GINA follows a similar 5-step approach.)
Important change in NVL 2024: SABA monotherapy is obsolete
The classic SABA monotherapy (e.g. salbutamol/albuterol alone as needed) is now considered obsolete. The recommendation is that every as-needed inhalation also contain an inhaled corticosteroid (ICS) — either as a fixed combination or alongside an ICS controller. This aligns with international GINA guidance.¹˒⁴
Reliever medications — for acute symptoms
Reliever 1
SABA (e.g. salbutamol/albuterol)
Short-acting bronchodilator — works within a few minutes and has traditionally been used as a rescue inhaler. SABA monotherapy alone is no longer recommended per NVL 2024.¹
Reliever 2
ICS/formoterol as needed (NVL 2024)
Fixed combination of inhaled corticosteroid (ICS) and fast-acting bronchodilator (formoterol) — usable as as-needed therapy as early as the lower steps. Advantage: every as-needed inhalation automatically includes an anti-inflammatory component. In steps 1–2 still formally off-label, but recommended by NVL and GINA.¹˒⁴
Maintenance therapy (controllers) — daily anti-inflammatory treatment
Step 1–2
Mild asthma
Low-dose ICS (e.g. budesonide, fluticasone, beclomethasone) as a metered-dose or dry powder inhaler is usually the foundation. They can suppress the chronic airway inflammation. Alternatively, an ICS/formoterol fixed combination can be used purely as needed — e.g. for patients who have only occasional symptoms.¹
Step 3
Moderate asthma
- ICS + LABA (long-acting bronchodilator) as a fixed combination — e.g. budesonide/formoterol, fluticasone/salmeterol, fluticasone/vilanterol, beclomethasone/formoterol
- SMART/MART concept: budesonide/formoterol as a single inhaler used 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 aspirin-exacerbated respiratory disease¹
Step 4
Severe asthma
- ICS (medium to higher dose) + LABA as a fixed combination
- Optionally with the addition of LAMA (e.g. tiotropium) as triple therapy (ICS + LABA + LAMA)
- Per NVL 2024, an adequately long trial at step 4 should generally precede the use of biologics¹
Step 5
Severe uncontrolled asthma — biologics
For people with asthma not adequately controlled despite maximal inhaled therapy. These antibody medications selectively block inflammatory mediators and are used in specialized centers.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 — similar mechanism to mepolizumab
- Dupilumab (Dupixent): anti-IL-4/IL-13 — for type 2 inflammation, often also effective with coexisting 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. Long-term oral steroid therapy should be avoided where possible per NVL 2024 — the available biologic options should be evaluated first. Learn more:
Stopping cortisone.
¹
Don't fear inhaled corticosteroids
ICS at the recommended dose is generally considered safe — including for children. It acts locally in the airways with comparatively small systemic effects. Weight gain, osteoporosis or diabetes primarily concern systemic steroid use. Tip: rinse your mouth after inhaling — that significantly reduces the risk of oral thrush.
