World Asthma Day

How asthma manifests and why exacerbations are dangerous

Bronchial asthma is a chronic inflammatory disease. It can manifest as wheezing and rhonchi, dyspnea, chronic cough, and chest tightness that worsens at night.

Sometimes symptoms worsen acutely, this is called an exacerbation. Wheezing, rhonchi, and chest tightness intensify, and syncope can even occur.

Why asthma develops

Allergic asthma is the most common and easily recognized variant of the disease. However, other phenotypes exist: non-allergic asthma, late-onset asthma (in adults), occupational asthma (which can also be allergic), and obesity-associated asthma.

Many patients note that symptoms appeared after viral illness or exposure to occupational hazards. Therefore, even if someone never suffered from allergies, the probability of developing asthma still exists.

Individuals with asthma have airways sensitive to triggers that don't affect others. These triggers are unique to each person. Asthma can be triggered by allergens: dust mites, pollen, mold, and pet dander.

Airborne irritants to which a person isn't allergic can also trigger an exacerbation. These include cigarette smoke, smog, dust, and strong odors of paint, gasoline, or perfumes. Asthma exacerbations can be triggered by dry wind, cold air, strong emotions, certain medications (such as aspirin and NSAIDs), and respiratory infections.

Physical exercise can also be asthma triggers. However, this doesn't mean sports are contraindicated. With appropriate treatment, limiting physical activity won't be necessary. Moreover, training respiratory muscles can help reduce treatment volume and duration.

At what age can asthma develop

Bronchial asthma more commonly develops in children or adolescents, but can begin at any age.

Additionally, newly emerging asthma in adulthood sometimes represents a recurrence of childhood asthma that wasn't diagnosed at that time. This often occurs if there was a prolonged period of spontaneous remission, when all symptoms resolved independently for an extended period.

There's a small risk of developing asthma at any age, even without previous symptoms. The probability of developing it varies among different individuals depending on sex, age, and other factors. For example, women have higher average risk, including symptoms that often emerge during menopause. A distinct type of bronchial asthma characteristic of adults is occupational asthma, whichaccounts for 5–20% of new adult cases.

Asthma is also common in individuals over 65. In these cases, symptoms are less likely to resolve spontaneously without treatment, making therapy essential.

Why asthma remains a problem

According to WHO estimates, hundreds of millions of people worldwide suffer from bronchial asthma, with over 450,000 related deaths recorded annually. A significant proportion of severe exacerbations is associated with delayed diagnosis, absence of baseline therapy, or incorrect inhaler technique. GINA in its latest updates emphasizes: with timely diagnosis and treatment, most patients can live with minimal symptoms without limiting themselves in education, work, or physical activity.

How asthma is controlled

Contemporary, appropriately selected therapy in most cases reduces disease manifestations to nearly zero, though therapy has undergone significant evolution.

The first inhaled glucocorticoid for controlling asthma exacerbations was applied and developed in 1972. Physicians prescribe this drug class most frequently: they're safe and effective, helping prevent exacerbations and slow disease progression.

Bronchial asthma isn't always accompanied by classic suffocation attacks, sometimes only coughing occurs. If asthma is poorly controlled (the person isn't receiving treatment or hasn't been prescribed appropriate medications), the probability of suffocation attacks increases. The physician's task is to select therapy that will be effective and educate the patient on management during exacerbations.

How asthma is treated

Asthma is typically treated using an inhaler, a small device that delivers medication directly to the lungs. 

Inhalers are classified into three types:

• Rescue inhalers for rapid asthma symptom relief (bronchodilators). They can be used up to three times per week. They can also be used prophylactically before exercise.
• Daily controller inhalers to prevent asthma symptoms. They must be used even when symptoms are absent. They contain steroid medications but, since used only in the lungs, have relatively low risk of adverse effects. This is the primary asthma treatment.
• Combination inhalers. Combine functions of rescue and controller inhalers. They must also be used continuously.

Baseline therapy must be administered once or twice daily regardless of whether symptoms are present, for the duration prescribed by the physician. Typically these are inhaled agents with low doses of glucocorticosteroids: budesonide, beclomethasone, and others. 

Sometimes patients experience the need for emergency relief, rapid-acting bronchodilator inhalers. Such inhalations expand airways, helping restore breathing. Their effect begins within 5–15 minutes, but they cannot be used continuously. If someone uses emergency relief for more than one day consecutively or requires 6–8 doses of such an inhaler daily or more than one canister per month, this represents loss of disease control. They must urgently consult a physician to prescribe or adjust baseline therapy.

Sometimes medications alone are insufficient. Oral agents may be prescribed if one inhaler cannot adequately manage asthma. Most often these are leukotriene receptor antagonists (montelukast, zafirlukast, pranlukast, pobilukast, and others). Sometimes theophylline is prescribed, which helps relax muscles around airways and keeps them patent. For severe asthma, oral steroids may be prescribed, though they have significant adverse effects: weight gain, bone weakening, and hypertension.

Some individuals with severe asthma are prescribed injectable biologic medications such as benralizumab, omalizumab, mepolizumab, or reslizumab. They're typically administered once every few weeks, but such medications are indicated only for a limited subset of patients with specific asthma phenotypes and aren't appropriate for everyone.

Bronchial thermoplasty is sometimes utilized to treat severe asthma. During the procedure, the physician passes a thin flexible catheter through the airway that delivers thermal energy: heat affects smooth muscle around bronchi, reducing their mass and propensity to narrow. Breathing becomes easier and exacerbations become less frequent. According to large study results, for selected patients the procedure reduces exacerbation frequency and is considered relatively safe long-term; treatment is typically conducted over three sessions, and the effect remains valid for 10 or more years.

What's changing in treatment approaches

Today, the bronchial asthma treatment strategy isn't built on emergency management of exacerbations but on their long-term prevention and personalized disease control. Contemporary global guidelines (GINA) emphasize anti-inflammatory therapy, reducing risk factors, and accounting for individual disease characteristics (phenotype) in each patient.

A key change in recent years is recognition that using only rescue medications (short-acting beta2‑agonists, SABA) for regular asthma treatment in adults and adolescents is unacceptable. Such monotherapy increases the risk of severe exacerbations. Now all patients in this demographic are recommended therapy, necessarily including inhaled glucocorticosteroids (ICS), either for daily use or according to an "as-needed" regimen in combination with bronchodilators.

GINA proposes two main strategies for initial therapy:

1. Preferred pathway: Using a fixed combination of low-dose ICS with formoterol bronchodilator for both daily control and symptom relief.
2. Alternative pathway: Using SABA "as needed" for symptom relief, but with mandatory simultaneous use of an ICS inhaler.

This approach significantly reduces exacerbation frequency and need for systemic steroid administration, particularly in patients with mild to moderate asthma.

Asthma patients may require lifelong medication

Asthma is a chronic disease that can be controlled but cannot be cured. Asthma treatment should be flexible and based on symptom changes. For example, if it's well controlled, the physician may prescribe fewer medications. If it worsens, additional medications and physician visits may be necessary.

Patients should always have an action plan stating when to administer certain medications, when to increase or decrease doses depending on symptoms. The plan should also list triggers and avoidance strategies.

Why vaccination is important for asthma

Vaccination is appropriate when the patient's condition is stabilized. Individuals with bronchial asthma, particularly children and the elderly, are at increased risk of pneumococcal infection, they definitely require this vaccine.

Individuals with asthma also have higher risk of serious influenza complications, even if the disease is mild or symptoms are well controlled with medication. They should vaccinate annually against this infection as well as COVID-19.

Can you live with asthma in a large city

Patients should attempt to avoid triggers that worsen disease symptoms. Such triggers can include outdoor and indoor air pollution, plant pollen, indoor mold, tobacco smoke, household chemical aerosols, occupational factors (dust, chemical vapors at production facilities), and viral infections. Asthma occurs not only in large cities but also in smaller municipalities and even in rural areas, particularly where air quality is compromised. Even distant from metropolitan areas, there are triggers that can provoke disease onset or exacerbation.

How bronchial asthma is treated in Russia

In Russia, diagnosis and treatment of bronchial asthma are based on Ministry of Health-approved clinical practice guidelines for adults and children, which since 2025 are mandatory for care provided under the mandatory health insurance system. For patients with severe eosinophilic or allergic asthma not responding to standard treatment, the principal classes of biologic medications are registered in Russia and utilized: omalizumab, anti‑IgE for combination therapy; mepolizumab, reslizumab, benralizumab, anti‑IL‑5/anti‑IL‑5R for eosinophilic asthma; dupilumab, blocker of interleukin 4 and 13 receptors. In some cases, these medications are utilized within state programs (including high-technology medical care and other subsidized medical provision mechanisms), enabling treatment through budget funding. Treatment decisions are made by specialized medical commissions at tertiary centers according to strict criteria.

For patients with proven allergen-related asthma (pollen, house dust mites), allergen-specific immunotherapy (ASIT) is employed, modifying the immune response.

"Asthma schools" operate in virtually all major pulmonology and allergy centers, where patients are taught inhalation technique, self-monitoring (including peak flow measurement), and diary maintenance. The treatment program additionally includes respiratory exercises, physical training, and speleotherapy and climate therapy at resorts (Crimea, Caucasus, Altai).

Real-world practice demonstrates that even with a formally established system, part of the financial burden falls on patients: according to survey data from the Put K Zdorovyu ("Path to Health") association and the National Medical Research Center in pulmonology profile at Sechenov University's Institute of Clinical Medicine, baseline therapy is prescribed to 88% of respondents, but only approximately two-thirds receive it free of charge, with over half experiencing delays and medication supply interruptions. Approximately 68% of respondents spend 10-30% of family budgets on medications, inhalers, and other medical services for symptom management, creating a gap between the normative treatment model and economic reality for patients.