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Asthma in adults
Asthma is variable, reversible airflow obstruction driven by inflammation, so the basis of treatment at every step is an inhaled corticosteroid — and under GINA an adult is never treated with a SABA alone.
Why it matters in the exam
Questions test three decision points. The first is the diagnosis: reversibility on spirometry (a rise of more than 12% and more than 200 mL in FEV1 after a bronchodilator), variability in peak flow, or a positive challenge test. The second is choosing the next treatment step: the candidate must know that the preferred track is low-dose ICS-formoterol as needed at steps 1–2 and the same inhaler as maintenance and reliever therapy (MART) at steps 3–4, and that at step 5 the phenotype is assessed and biological therapy is considered.
The third is the acute attack in the emergency department. Markers of severity must be recognised (speaking in single words, heart rate above 120, saturation below 90%, PEF of 50% or less), as well as life-threatening signs (drowsiness, a "silent chest", a normal or rising PaCO2). A well-known distractor is a "normal" PaCO2 in a severe attack — a sign that the respiratory muscles are tiring and that respiratory failure is near. Questions also feature non-selective beta-blockers as a trigger, aspirin sensitivity with nasal polyps, and intravenous magnesium sulfate when the first treatment fails.
Key points
- Diagnosis: reversibility of more than 12% and more than 200 mL in FEV1.
- Every step contains an ICS; no SABA alone in adults.
- ICS-formoterol as needed at steps 1–2, and MART at steps 3–4.
- Severe attack: SABA, ipratropium, prednisolone 40–50 mg and intravenous magnesium 2 g if there is no response.
- Drowsiness, a silent chest and a normal or rising PaCO2 are life-threatening signs.
Summary table
| Step (GINA, Track 1) | Preferred treatment | Alternative / add-on | Note |
|---|---|---|---|
| 1–2 | Low-dose ICS-formoterol as needed | Low-dose ICS taken whenever a SABA is used | Never a SABA alone |
| 3 | Low-dose ICS-formoterol as maintenance and reliever (MART) | Low-dose ICS-LABA + SABA | Check technique and adherence before stepping up |
| 4 | Medium-dose ICS-formoterol (MART) | Medium- to high-dose ICS-LABA | Consider a LAMA |
| 5 | Referral for phenotyping; add a LAMA | Biologic: anti-IgE, anti-IL5 or anti-IL4R | Avoid maintenance oral steroids where possible |
| Severe attack | Repeated SABA, ipratropium, prednisolone 40–50 mg for 5–7 days | Intravenous magnesium sulfate 2 g over 20 minutes | Saturation target 93%–95% |
A free exam question
בת 27 , סובלת מאסתמה ומטופלת במשאף Beclomethasone 200 מק"ג פעמיים ביום, אבל בחודש האחרון נזקקת למשאף Salbutamol פעם או פעמיים ביום עם תגובה טובה. כעת שוב קוצר נשימה. בהאזנה צפצופים על פנ י שתי הריאות. מה יש להמליץ כעת? (the question as examined, in Hebrew)
- א. הוספת Montelukast פעם ביום
- ב. מתן Prednisone 40 מ״ג וירידה הדרגתית
- ג. החלפת המשאף למשאף משולב Salmeterol/Fluticasone
- ד. להמשיך Beclomethasone ו- Salbutamol 3 פעמים ביום
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Sources
- Global Initiative for Asthma (GINA) Global Strategy for Asthma Management and Prevention, 2024 — Diagnosis, stepwise treatment (Track 1) and management of exacerbations
- Harrison's Principles of Internal Medicine, 21st edition (2022) — Asthma
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.
See also: in children: Asthma in children