Asthma: Getting Better Control

How to know whether your asthma is really controlled — and what to do if you still rely on your reliever

Asthma can be deceptive.

You may think it is “not too bad” because you have not been to hospital.

You may be able to exercise most days.

You may only use your reliever when you need it.

But if you are regularly wheezing, waking at night, avoiding exercise, or reaching for a reliever inhaler again and again, your asthma may not actually be well controlled.

Good asthma treatment is not just about getting through an attack.

The aim is to:

• prevent symptoms
• keep you active
• reduce flare-ups
• protect lung function
• minimise the need for oral steroids
• reduce the risk of a serious asthma attack.

And for many people, better control starts with something surprisingly simple:

making sure the treatment you already have is the right treatment — and that you are actually getting it into your lungs.

What is asthma?

Asthma is a long-term condition in which the airways become more sensitive and inflamed.

At different times, the muscles around the airways can tighten and the airway lining can swell and produce mucus.

This can cause:

• wheeze
• cough
• chest tightness
• shortness of breath.

Symptoms can vary considerably from day to day.

Some people have obvious attacks.

Others mainly notice exercise limitation, night-time cough, breathlessness with colds or a recurring feeling that they cannot quite get a full breath.

What does well-controlled asthma look like?

In practical terms, well-controlled asthma means that asthma is rarely interfering with your life.

You should usually be able to:

• exercise normally
• sleep without asthma waking you
• get through most days without troublesome symptoms
• avoid repeated asthma attacks
• use little rescue medication.

If you have simply adapted your lifestyle to avoid triggering symptoms, that does not necessarily mean your asthma is controlled.

For example:

“I don’t get wheezy because I stopped running.”

is not the same as:

“I can run without asthma limiting me.”

What are signs that my asthma may not be controlled?

Consider reviewing your asthma if you are:

• having symptoms more than occasionally
• waking at night because of asthma
• regularly needing a reliever
• avoiding exercise because of breathlessness or wheeze
• missing work or school
• having repeated flare-ups
• needing oral steroid courses
• attending urgent care or hospital
• noticing that colds repeatedly “go to your chest”.

The exact number of symptoms is less important than the pattern.

If asthma is regularly affecting what you do, how you sleep, or how often you need rescue treatment, it deserves review.

Why isn’t the blue reliever enough?

For many years, people with asthma were commonly given a blue reliever such as salbutamol and told to use it when symptoms occurred.

Salbutamol can still be very effective at quickly relaxing the muscles around the airways.

But it does not treat the underlying airway inflammation.

Current Australian guidance therefore does not recommend treating adults or adolescents with a short-acting reliever such as salbutamol alone, even when symptoms are relatively infrequent.

Instead, asthma treatment should usually include an inhaled corticosteroid, or ICS, because this reduces the risk of severe flare-ups.

What is an anti-inflammatory reliever?

Some combination inhalers contain:

• an inhaled corticosteroid to treat inflammation
• formoterol, a medicine that opens the airways quickly.

Certain ICS-formoterol inhalers can therefore be used when symptoms occur, providing both rapid relief and anti-inflammatory treatment at the same time.

For many adults and adolescents with asthma, current Australian guidance prefers an ICS-formoterol reliever-based approach, including as-needed low-dose budesonide-formoterol in suitable patients.

This is sometimes called an anti-inflammatory reliever, or AIR.

It is different from simply taking a blue reliever.

Do not change inhalers or treatment strategy without checking how your specific inhaler is intended to be used.

Does that mean Ventolin is dangerous?

No.

Salbutamol is an effective bronchodilator and remains an important medicine for treating acute asthma.

The concern is relying on it as the only treatment for ongoing asthma.

A reliever can make you feel better quickly because the airways open.

But if airway inflammation remains untreated, the underlying risk of a serious flare-up may still be present.

The goal is not to fear the blue inhaler.

It is to make sure your asthma treatment also addresses inflammation and future risk.

What is a preventer?

A preventer usually contains an inhaled corticosteroid.

These medicines reduce inflammation and sensitivity in the airways.

Depending on the inhaler and your asthma pattern, treatment may be taken:

• every day
• only when symptoms occur as part of an ICS-formoterol strategy
• as both regular maintenance treatment and extra doses when symptoms occur.

The correct approach depends on which inhaler you use.

Do not assume every combination inhaler can be used in the same way.

What is MART?

Maintenance-and-reliever therapy, or MART, uses the same ICS-formoterol inhaler for:

regular daily maintenance treatment

additional doses when asthma symptoms occur.

This can simplify treatment and allows the anti-inflammatory component to increase during periods when asthma is becoming more active.

MART is suitable for some adults and adolescents at several treatment levels.

However, MART only applies to particular medicines and inhaler combinations.

Your GP, pharmacist or asthma nurse should explain exactly how your inhaler is intended to be used.

How do I know whether I am using the right inhaler?

Start with three questions:

1. What is the name of my inhaler?
2. Is this my regular treatment, my reliever, or both?
3. How many doses should I take when I am well and when symptoms worsen?

If you cannot confidently answer those questions, bring the inhaler itself to your next appointment.

It is surprisingly common for someone to have several inhalers at home but no clear idea which one does what.

Inhaler technique matters more than most people realise

You can have the right medicine at the right dose and still have poorly controlled asthma if very little medication reaches your lungs.

Incorrect inhaler technique is extremely common.

Common problems include:

• not breathing out before inhaling
• inhaling too quickly or too slowly for the device
• poor coordination with a pressurised puffer
• not inhaling deeply enough
• not holding the breath afterwards
• failing to prepare or load a dry-powder device correctly
• using an empty inhaler
• forgetting to remove a cap
• incorrect spacer use.

A thirty-second inhaler-technique check can sometimes improve asthma more than adding another medicine.

Do I need a spacer?

If you use a pressurised metered-dose inhaler, a spacer can make it easier to deliver medicine effectively into the lungs.

Spacers are particularly useful:

• during asthma attacks
• for children
• when coordination is difficult
• with inhaled corticosteroid puffers.

Whether a spacer is relevant depends on the inhaler device you use.

Dry-powder inhalers and many other devices do not use one.

Why should I rinse my mouth after some inhalers?

Inhaled corticosteroids can occasionally cause:

• oral thrush
• hoarse voice
• throat irritation.

Rinsing your mouth and spitting out the water after corticosteroid inhalation can reduce local side effects with many devices and regimens.

Using correct technique and a spacer where appropriate can also help.

The amount of steroid delivered to the rest of the body from standard inhaled treatment is generally much lower than with repeated courses of oral steroid tablets.

Is inhaled steroid treatment safe?

For most people, inhaled corticosteroids are an effective and relatively low-risk way to control asthma.

The bigger long-term concern is often poorly controlled asthma and repeated courses of oral corticosteroids, rather than appropriate low-dose inhaled treatment.

Oral steroids can be very useful during significant attacks, but repeated exposure can contribute to problems such as:

• osteoporosis
• diabetes
• weight gain
• high blood pressure
• cataracts
• infections
• mood and sleep disturbance.

If you are needing repeated courses of prednisolone or similar medication, that is a reason to reassess your asthma rather than simply continuing the same pattern.

What triggers asthma?

Different people have different triggers.

Common ones include:

• viral respiratory infections
• smoke
• vaping
• air pollution
• pollen
• dust mites
• animal allergens
• mould
• cold air
• exercise
• occupational exposures.

Some medicines can also worsen asthma in susceptible people.

But avoiding every possible trigger is usually neither realistic nor necessary.

Good underlying asthma control often makes you less vulnerable to triggers.

What about allergies?

Asthma and allergic conditions often occur together.

People with asthma may also have:

• allergic rhinitis
• hay fever
• eczema
• sinus disease.

An untreated blocked or inflamed nose can make breathing symptoms and sleep worse.

If you are constantly congested, sneezing or experiencing nasal symptoms, it is worth treating the upper airway as part of the overall picture rather than thinking only about the lungs.

Can exercise trigger asthma?

Yes.

Exercise can cause bronchoconstriction in some people, particularly when asthma is not well controlled.

Typical symptoms include:

• cough
• wheeze
• chest tightness
• unusual breathlessness during or after exercise.

But the answer is usually not to stop exercising.

Well-managed asthma should allow most people to remain physically active.

If exercise repeatedly causes symptoms, review overall asthma control, inhaler technique and whether another condition might be contributing.

Breathlessness during exercise is not always asthma.

What else can look like asthma?

Not every episode of breathlessness, cough or wheeze is caused by asthma.

Other possibilities include:

• respiratory infection
• chronic obstructive pulmonary disease
• vocal cord or laryngeal problems
• reflux
• cardiac disease
• anxiety or panic
• deconditioning
• obesity
• anaemia.

This is particularly important if the diagnosis was made years ago without objective testing or if treatment is not working as expected.

Do I need spirometry?

Often, yes.

Spirometry is a breathing test that measures how much air you can blow out and how quickly you can blow it.

It can help:

• support an asthma diagnosis
• assess lung function
• reconsider the diagnosis if treatment is not working.

A normal spirometry test on one particular day does not always exclude asthma because asthma varies over time.

Sometimes testing needs to be repeated or combined with other assessments.

What about peak-flow monitoring?

Most people do not need to measure peak flow every day indefinitely.

However, peak-flow monitoring can be helpful for selected people, particularly when:

• symptoms are difficult to interpret
• asthma is severe
• objective monitoring helps recognise deterioration
• it forms part of an individual asthma action plan.

What is an asthma action plan?

A written asthma action plan tells you what to do when your asthma is:

• well controlled
• beginning to worsen
• becoming severe.

It should be personalised to your own medicines and may use symptoms, peak flow or both.

A good action plan explains:

• your usual treatment
• what changes to make if symptoms increase
• when to seek medical help
• what to do during an asthma attack.

A generic internet action plan is not as useful as one matched to the inhalers you actually use.

What if I only get asthma when I have a cold?

Viral infections are one of the commonest triggers for asthma flare-ups.

If every cold produces prolonged cough, wheeze, chest tightness, significant shortness of breath or the need for oral steroid treatment, your asthma may still need preventive treatment even if you feel completely well between infections.

Asthma control is partly about preventing the bad weeks, not just improving the good ones.

What if I only use my reliever before exercise?

That may still deserve review.

Occasional pre-exercise medication may be appropriate for some people, but repeatedly needing a bronchodilator to exercise can indicate airway hyperresponsiveness or suboptimal control.

Your treatment plan should allow you to exercise safely and confidently.

What if my inhaler seems to have stopped working?

Do not simply keep taking more and more doses without understanding why.

Consider:

• whether the inhaler is empty
• whether your technique has changed
• whether the device has expired
• whether asthma is genuinely worsening
• whether the symptoms are actually being caused by something else.

If you are needing substantially more reliever than usual, treat that as a warning sign.

When should I have my asthma reviewed?

Arrange a review if:

• symptoms are becoming more frequent
• you are using more reliever
• you are waking at night
• exercise is becoming harder
• you have had an asthma attack
• you needed oral steroids
• you attended hospital or urgent care
• you are unsure how your inhalers should be used
• your inhaler technique has not been checked recently
• you do not have an asthma action plan.

After an asthma flare-up or emergency visit, arrange an asthma review even if you feel better again. The episode is an opportunity to check treatment, inhaler technique and your action plan.

A review should usually involve more than simply issuing another prescription.

What should an asthma review include?

A useful asthma review may include:

• current symptom control
• attacks since the last review
• reliever use
• oral steroid use
• inhaler adherence
• inhaler technique
• smoking or vaping
• allergy and nasal symptoms
• exercise
• triggers
• lung-function testing when appropriate
• your asthma action plan.

Before increasing treatment, it is particularly important to check adherence and inhaler technique.

There is little benefit in prescribing a stronger inhaler if the real problem is that the current one is rarely being used or is being used incorrectly.

Can asthma treatment ever be reduced?

Yes.

Asthma treatment does not always need to move upward.

If asthma has been well controlled for a sustained period, your clinician may consider carefully stepping treatment down while maintaining adequate anti-inflammatory protection.

The goal is the lowest effective treatment that keeps symptoms and future risk controlled.

Do not stop a preventer abruptly simply because you have felt well for several months without discussing the plan first.

Feeling well may be evidence that the treatment is working.

Questions people commonly ask

I hardly ever wheeze. Can I still have asthma?

Yes.

Some people mainly experience cough, breathlessness or chest tightness.

Asthma symptoms vary between people.

Is asthma only serious if I have been hospitalised?

No.

Hospitalisation is one marker of severe asthma risk, but repeated symptoms, reliever dependence and oral steroid use can all indicate inadequate control.

Can asthma disappear?

Symptoms can become less active for long periods, particularly from childhood into adulthood.

But asthma can also return.

Do not assume the diagnosis is permanently gone simply because you have not needed treatment recently.

Should I use my preventer only when I’m wheezy?

That depends on the treatment regimen.

Some inhaled corticosteroid-formoterol regimens are specifically designed to be taken when symptoms occur.

Traditional preventers need regular use.

Follow the instructions for your particular inhaler, not another person’s asthma treatment.

Are steroid inhalers addictive?

No.

Inhaled corticosteroids are not addictive.

If symptoms return after stopping treatment, that usually reflects returning airway inflammation rather than dependence on the medicine.

I feel fine. Why should I still have an action plan?

Because asthma can worsen quickly during infections, allergen exposure or other triggers.

An action plan is most useful when it is prepared before you need it.

When is asthma an emergency?

Asthma can occasionally become life-threatening.

Call Triple Zero (000) for severe or rapidly worsening breathing difficulty.

Warning signs include:

• struggling to speak in full sentences
• breathing that is rapidly worsening
• becoming very distressed or exhausted
• the reliever providing little or only brief benefit
• lips appearing blue or grey
• drowsiness or confusion
• feeling that you simply cannot get enough air.

During an asthma attack, follow your asthma action plan and use your prescribed reliever.

If symptoms are severe or are not improving promptly, call 000.

Before your GP appointment

Bring your actual inhalers if possible.

It helps to know:

• how often you have symptoms
• whether asthma wakes you at night
• how often you use your reliever
• whether you have needed oral steroids
• any emergency or hospital visits
• what happens during exercise
• whether you smoke or vape
• whether allergies or nasal symptoms are troublesome.

If you have several inhalers, bring all of them.

Your GP or pharmacist can then check what each one is for and watch how you use it.

Start with one action

Take out your asthma inhaler and ask yourself:

“Do I know exactly what this inhaler does, when I should use it, and whether my technique is correct?”

If the answer to any part is no, take it to your GP or pharmacist and have the technique checked.

That small step can make a surprisingly large difference.

The bottom line

Good asthma control means more than avoiding hospital.

It means being able to sleep, exercise and live normally without regularly battling asthma symptoms.

For adults and adolescents, current Australian treatment has moved away from relying on a blue reliever alone. Asthma treatment should generally include an inhaled corticosteroid, often through an anti-inflammatory reliever or another ICS-containing regimen.

If your asthma is not controlled, do not immediately assume you need stronger medicine.

First check:

• whether the diagnosis is right
• whether you are actually taking the treatment
• whether the inhaler technique is correct
• whether triggers or other conditions are contributing
• whether your action plan is up to date.

And if you are repeatedly reaching for your reliever, waking at night, limiting exercise or needing courses of oral steroids, do not settle for “my asthma has always been like this.”

Better control is often possible.