Asthma in adults and children

1Definition

Asthma is a chronic inflammatory disease of the airways with variable symptoms (wheeze, breathlessness, chest tightness, cough) and variable airflow limitation that changes over time and in intensity, often reversing with treatment or on its own.

An acute exacerbation (attack) is a worsening of symptoms and lung function beyond the person's usual, needing a change in treatment.

2Classification and grading

Types

• Allergic (extrinsic): often starts in childhood; linked to eczema, allergic rhinitis and family history.
• Non-allergic (intrinsic): often adult-onset.
• Occupational asthma: caused by agents at work (flour, grain dust, chemicals). Relevant for the farmer cases.
• Exercise-induced bronchoconstriction: narrowing during or after exercise.
• Asthma–COPD overlap in long-term smokers (W20 case).

Severity of an acute attack (BTS/SIGN)

Asthma control

Asthma is well controlled when daytime symptoms and reliever use are rare, there is no night waking and no activity limitation. The Asthma Control Test (ACT, adults) and Childhood ACT score this.

3Causes, risk factors and triggers

• Risk factors: family history, atopy (eczema, hay fever), obesity, smoking and passive smoke, prematurity and early viral infections.
• Triggers: respiratory infections; house dust mites, pollen, mould, animal fur, cockroaches; smoke, chulha smoke, mosquito coils, incense; cold air and weather change; exercise; strong smells; emotional stress; some medicines (aspirin, beta-blockers); occupational dusts.

4Pathophysiology to impairments

1. A trigger activates inflammatory cells in the airway wall (mast cells, eosinophils).
2. Three things narrow the airways: bronchospasm (smooth muscle contraction), mucosal swelling and thick mucus plugs.
3. Airflow is obstructed mainly on breathing out, so air is trapped: hyperinflation, wheeze and breathlessness.
4. Uneven ventilation lowers oxygen; at first CO₂ falls because the patient breathes fast. A normal or rising CO₂ in an attack is a danger sign of tiring.
5. Repeated inflammation thickens the airway wall over years (remodelling), so some obstruction can become fixed.
6. Fear of attacks leads to avoiding exercise, so fitness falls and breathlessness rises (as in COPD). Some patients also develop a dysfunctional, fast upper-chest breathing pattern.

5Clinical features

• Episodic wheeze, breathlessness, chest tightness and cough, often worse at night or early morning, with triggers.
• Symptoms come and go; the patient may be completely well between attacks (W22 girl).
• During an attack: fast breathing, use of accessory muscles, prolonged expiration with wheeze, difficulty speaking, anxiety; a "silent chest" means very little air is moving (life-threatening).
• Children: cough at night or with play, avoiding running games, missing school.

6Investigations

7Medical management

• Inhaled steroid-containing treatment is the base for everyone. GINA no longer recommends a short-acting reliever such as salbutamol on its own at any step.
• Adults and adolescents: the preferred plan (GINA Track 1) uses low-dose ICS–formoterol as the reliever, and also as daily maintenance at higher steps.
• Add-on treatment for severe asthma: long-acting antimuscarinics, leukotriene antagonists, biologic injections.
• Inhaler technique and use of a spacer (with a mask for young children) are essential.
• Acute attack: repeated reliever by spacer or nebuliser, oral steroids, controlled oxygen (BTS target SpO₂ 94–98%), ipratropium and magnesium in severe attacks; ICU and ventilation if life-threatening.
• Avoid triggers; stop smoking; treat rhinitis; written action plan.

The W22 girl takes only SOS salbutamol and has monthly attacks. Under current guidance this needs medical review for a steroid-containing plan. As a physio, encourage that review while you treat.

8Complications and prevention

9PT assessment

• History: triggers, frequency of attacks and admissions, night symptoms, reliever use, medicines and inhaler technique, smoking, occupation and dust, home environment, school or work absence, sport and play.
• Observation: breathing pattern and rate, accessory muscles, posture, ability to speak in sentences.
• Auscultation: wheeze, prolonged expiration, crackles.
• Peak flow and SpO₂; ABG in severe attacks.
• Exercise capacity: 6MWT or shuttle test (children: shuttle or step test), with SpO₂ and peak flow before and after.
• Breathing pattern questionnaire (Nijmegen) if dysfunctional breathing is suspected.
• Outcome measures: ACT or Childhood ACT, Asthma Quality of Life Questionnaire (PAQLQ for children), peak-flow diary, exercise test, school or workdays missed, attacks per year.

10PT diagnosis by ICF

Draw the six-box ICF model (see the IHD page), then fill it from the case.

Worked example from a real paper (W22, 5 + 7 + 3 marks)

"A seven year old girl diagnosed as having bronchial asthma since one year is referred for physiotherapy. This condition has affected her attendance at school as she gets breathless during acute exacerbation and her mother carries her bag to school every day. Her parents are worried about sending her to play with her friends and insist on playing indoor sedentary games. Her teachers also do not allow her to participate in outdoor play due to fear of breathlessness. The girl however wishes to play. She is prescribed SOS salbutamol inhaler and she is absolutely fine between acute episodes which come once a month. (i) Discuss the content of parent and teacher counseling. (ii) Plan rehabilitation program for this girl. (iii) Which outcome measures will show her improvement following rehabilitation?"

11Problem list and goals

12PT management

1. Acute exacerbation (7 marks in S22; W18 and W20 cases)

• Positioning: high sitting or forward-lean sitting with arms supported, to ease the work of breathing.
• Breathing control and relaxation: slow, gentle tidal breathing with the lower chest; relaxed shoulders; reassure and calm. Avoid deep, forced breathing during bronchospasm.
• Oxygen and nebulised bronchodilator as prescribed; time airway clearance after the bronchodilator.
• Airway clearance once bronchospasm eases, if mucus is present: ACBT with gentle huffs (see below).
• Avoid percussion and vibration during acute bronchospasm; they can worsen it.
• Encourage fluids; early mobilisation as the attack settles.
• Before discharge: inhaler technique, action plan, trigger avoidance, smoking cessation, follow-up.

Rationale of ACBT in asthma (7 marks in S17)

• Breathing control between other parts of the cycle prevents bronchospasm and fatigue; it is the "rest" in the cycle.
• Thoracic expansion exercises get air behind mucus plugs through collateral ventilation.
• Huffs move mucus without the airway narrowing and coughing fits that repeated forceful coughing can cause.
• The patient controls the pace, so it suits sensitive airways; stop and return to breathing control if wheeze increases.

2. Long-term management

• Breathing retraining (for example Papworth or Buteyko-based methods): nose breathing, slower rate, relaxed lower-chest pattern, reduced over-breathing. Improves asthma quality of life and symptoms (Cochrane 2020).
• Exercise training: aerobic training 2–3 times a week for at least 8–12 weeks improves fitness and quality of life without worsening asthma. Swimming is well tolerated (warm, humid air).
• Exercise-induced bronchoconstriction: warm up for 10–15 minutes (including short bursts), take the pre-exercise inhaler if prescribed, breathe through the nose, avoid cold dry air and pollution, cool down gradually.
• Inspiratory muscle training if the breathing muscles are weak.
• Posture and thoracic mobility; relaxation.
• Self-management: inhaler and spacer technique, peak-flow diary, action plan, trigger control.

Energy-conservation instructions (W19, 5 marks)

For the 25-year-old teacher recovering from an attack, energy conservation lowers breathlessness during daily tasks while fitness returns:

• Pace: slow, steady movement; breathe out during the effort part of a task ("blow as you go"); rest before becoming breathless; build activity up over 1–2 weeks after discharge.
• Plan: spread heavy jobs (washing, cleaning, shopping) through the week; do them at the best time of day; keep a reliever with you.
• Prioritise: drop or share tasks that are not essential while recovering.
• Position: sit for washing, ironing and cooking; keep things used often between waist and shoulder height; avoid prolonged bending and lifting overhead.
• At work: sit for part of each class; schedule classes to limit repeated stair climbs; use a whiteboard or dustless chalk; a microphone saves breath in large classes.
• Avoid triggers while working: damp dusting instead of sweeping, a mask for dusty jobs, no strong-smelling sprays.

3. Paediatric asthma rehabilitation (7 marks in S18; W22)

• Assessment and goals with the child and parents.
• Education: what asthma is, triggers, inhaler with spacer and mask, action plan, when to seek help.
• Breathing exercises as games: blowing bubbles, windmills, cotton-ball races (gentle long exhalation), "smell the flower, blow the candle".
• Exercise through play: warm-up games, interval play (short bursts with rest), skipping, cycling, swimming; 2–3 sessions a week, progressing time and intensity.
• Strengthening (body-weight games), posture and flexibility.
• Family and school involvement (counselling below).

Parent and teacher counselling (W22, 5 marks)

Outcome measures (W22, 3 marks): Childhood Asthma Control Test; Paediatric Asthma Quality of Life Questionnaire; peak-flow diary; 6-minute walk or shuttle test; school days missed; number of attacks and reliever use; time spent in active play.

By impairment

13Precautions, contraindications and stop criteria

14Education, lifestyle and home programme

Why education matters (7 marks in W21): most severe attacks and asthma deaths are linked to poor control: preventers not taken, relievers over-used, poor inhaler technique, and no plan for worsening symptoms. Self-management education with a written action plan and regular review reduces hospital admissions, emergency visits, night symptoms and days off work or school. Physiotherapists teach inhaler technique, breathing control, exercise and trigger control, and check them at every visit.

• Take preventer (steroid-containing) medicine as prescribed, even when well.
• Use the inhaler with a spacer; rinse the mouth after steroid inhalers.
• Follow your written action plan; keep a peak-flow diary.
• Avoid triggers; no smoking; keep bedding dust-free (wash in hot water, sun-dry).
• Exercise regularly with a warm-up; practise breathing exercises daily.
• Get the influenza vaccine; keep a healthy weight.
• Farmers and workers: wear a mask in dust, and ask about occupational triggers.

15Prognosis and discharge criteria

Prognosis: most people with asthma can be well controlled and lead normal lives, including sport. Many children improve in adolescence, but symptoms can return. Poor control, smoking and frequent oral steroid courses worsen the outlook.

Discharge after an attack: symptoms controlled, peak flow over about 75% of best, correct inhaler technique, written action plan, follow-up booked.

16Exam corner

Past questions (MUHS, 2016–2026)

• W18 Q3(a), 5 + 5 + 5 marks30-year-old farmer with breathlessness, chest tightness, unproductive cough and audible wheeze: acute exacerbation of asthma. Functional diagnosis, short- and long-term management.
• W20 Q3(a), 5 + 5 + 5 marks45-year-old farmer, known asthmatic, in the chest ward with wheeze, breathlessness, cough and sputum for 3 days, on optimal medical therapy; chronic smoker; married; sole earner. ICF, short- and long-term management.
• W22 Q4(a), 5 + 7 + 3 marksThe worked example in section 10.
• W19 Q3(b), 5 + 5 + 5 marks25-year-old teacher with allergic asthma and repeated exacerbations; admitted 2 days ago with a sudden attack, now stable. Functional diagnosis; short-term physiotherapy; energy-conservation instructions.
• S23 Q3(a), 15 marks12-year-old boy with allergic asthma who misses school in winter and the rainy season; 3 emergency visits in the past month. ICF with short- and long-term goals.
• 7-mark questionsRationale of ACBT in bronchial asthma (S17). Paediatric pulmonary rehabilitation for children with asthma (S18). Physiotherapy in acute exacerbation of asthma (S22). Importance of patient education in controlling asthma (W21). Physiotherapy for a child with asthma for 2 years (S25).

Technique cards for this topic: breathing exercises, nebulisers and inhalers, dyspnoea and energy conservation, scales, pulmonary rehabilitation, yoga.

Keywords to underline

variable airflow obstruction reversibility triggers bronchospasm breathing control relaxation forward-lean sitting no percussion in acute bronchospasm breathing retraining warm-up action plan inhaler with spacer

Answer skeleton: asthma long answer

1. Restate: age, job, triggers, severity, smoking, social role.
2. [ICF, 5] ICF from the case with reasoning.
3. [Short-term, 5] Acute care: positioning, breathing control, relaxation, oxygen and nebuliser timing, gentle ACBT, precautions.
4. [Long-term, 5–7] Breathing retraining, exercise training with warm-up, inhaler technique, action plan, trigger control, smoking cessation, counselling, outcome measures.

Draw these

• The peak-flow action plan zones (section 4)
• Forward-lean sitting position (stick figure)

Viva questions

1. How do you tell asthma from COPD on spirometry?
2. Why is a normal CO₂ worrying during an asthma attack?
3. Why avoid percussion in acute asthma?
4. How do you prevent exercise-induced bronchoconstriction?
5. What do you tell a teacher about a child with asthma?
6. Name three outcome measures for childhood asthma.