Asthma | MRCGP Topic Essentials

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Asthma | MRCGP Topic Essentials

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1. Why this matters for MRCGP

  • Asthma is a high-frequency AKT topic because diagnosis now depends on objective testing, not symptoms alone.
  • It is a high-risk SCA topic because poor inhaler technique, poor adherence, short-acting beta-2 agonist (SABA) overuse and weak safety-netting can all lead to preventable harm.
  • The key GP risk is either overdiagnosing asthma without objective evidence or under-recognising uncontrolled asthma and future attack risk.
  • Practical use matters: the GP must be able to explain inhaler roles, check technique, prescribe safely, review action plans and avoid unsafe reliever-only treatment.

2. GP Bottom Line

  • Do not confirm asthma without both a suggestive clinical history and a supporting objective test. Code as suspected asthma until confirmed.
  • Uncontrolled asthma changes the plan: reliever use 3 or more days per week, night waking, activity restriction, or any exacerbation needing oral corticosteroids should trigger review and optimisation.
  • SABA-only asthma treatment is unsafe: do not prescribe a short-acting beta-2 agonist without an inhaled corticosteroid (ICS).
  • Every asthma review is an inhaler review: observe technique, check adherence from prescription records, review control and update the personalised asthma action plan.
  • Exam trap: stepping up treatment before checking inhaler technique, adherence, occupational triggers, smoking or alternative diagnoses.

Type 2 diabetes in children and young people MRCGP infographic summarising key exam points, symptoms, safe confirmation, urgent action, management and follow-up.

3. 60 Second Exam Snapshot

  • Symptoms: variable wheeze, noisy breathing, cough, breathlessness or chest tightness; often worse at night, early morning or seasonally.
  • Triggers include exercise, allergens, irritants, viral respiratory tract infection, smoke, weather changes, nonsteroidal anti-inflammatory drugs and beta-blockers.
  • Adults and young people over 16: eosinophils above lab reference range or fractional exhaled nitric oxide (FeNO) 50 ppb or more supports diagnosis.
  • Children aged 5–16: fractional exhaled nitric oxide (FeNO) 35 ppb or more supports diagnosis.
  • If not confirmed, use bronchodilator reversibility with spirometry, or peak expiratory flow variability if spirometry is unavailable or delayed.
  • Age 12 and over: newly diagnosed asthma usually starts with as-needed anti-inflammatory reliever therapy (AIR) using low-dose inhaled corticosteroid/formoterol; maintenance and reliever therapy (MART) is used if highly symptomatic or uncontrolled.
  • Review at least annually, after any exacerbation, and 8–12 weeks after starting or adjusting asthma medicines.

4. Recognition and Diagnosis

  • Suspect asthma when symptoms are variable in type, timing and intensity. Cough, wheeze, chest tightness and breathlessness may come and go, be absent for weeks, worsen at night or on waking, or be triggered by exercise, viral infections, allergens, irritants, smoke, weather or certain medicines.
  • Risk factors that increase suspicion include personal or family atopy, allergic rhinitis, eczema, food allergy, obesity, smoking exposure, environmental exposures, preterm birth or low birth weight.
  • Examination may show expiratory polyphonic wheeze, but a normal examination does not exclude asthma. In a symptomatic patient, check oxygen saturation, respiratory rate, heart rate, ability to speak in sentences, accessory muscle use, and in children ability to feed.
  • Ask adults of working age about occupation. Suspect occupational asthma if symptoms are new, childhood asthma has returned, control is deteriorating, or airflow obstruction is unexplained, especially if symptoms improve away from work or on holiday.
  • Atypical features should make you pause before coding confirmed asthma: haemoptysis, systemic symptoms, crackles, clubbing, stridor, monophonic wheeze, chronic productive cough, persistent non-variable breathlessness, focal chest X-ray changes, faltering growth, persistent moist cough in a child, symptoms from birth, or unexplained restrictive spirometry.

5. AKT Essentials: What Changes the Answer

Diagnosis / recognition

  • Do not diagnose asthma from symptoms alone.
  • Record the basis for confirmed asthma in the medical record.
  • Inhaled corticosteroid treatment may make spirometry and FeNO results more likely to be normal.

Investigation / interpretation

  • Adults and young people over 16: diagnose asthma if blood eosinophils are above the laboratory reference range or FeNO is 50 ppb or more.
  • If not confirmed, measure bronchodilator reversibility. Adult threshold: forced expiratory volume in 1 second (FEV1) rises by 12% or more and 200 mL or more, or by 10% or more of predicted normal.
  • If spirometry is unavailable or delayed, measure peak expiratory flow (PEF) twice daily for 2 weeks. Use the best of three readings each time. Diagnose if variability is 20% or more.
  • Children 5–16: FeNO 35 ppb or more supports diagnosis.
  • Child bronchodilator reversibility threshold: FEV1 rises by 12% or more from baseline, or 10% or more of predicted normal.
  • In children aged 5–16, if FeNO, bronchodilator reversibility and PEF variability do not confirm asthma but suspicion remains, either perform house dust mite skin prick testing or measure total IgE and blood eosinophils.
    • Exclude asthma if there is no house dust mite sensitisation or total IgE is not raised.
    • Diagnose asthma if there is house dust mite sensitisation, or raised total IgE with eosinophils more than 0.5 × 10⁹/L.
    • Refer if diagnostic doubt remains.

Management / next best step

  • Treat immediately if acutely unwell or highly symptomatic; do objective tests later if needed.
  • Before stepping up treatment, check adherence, inhaler technique, smoking or vaping, occupation, environmental factors, psychosocial factors, comorbidities and alternative diagnoses.
  • Review response to treatment change after 8–12 weeks.

Medicines / safety

  • Do not prescribe a short-acting beta-2 agonist (SABA) without an inhaled corticosteroid (ICS).
  • Do not prescribe a long-acting beta-2 agonist (LABA) without an inhaled corticosteroid.
  • Non-formoterol ICS/LABA combinations (such as salmeterol-containing combinations) are not licensed for anti-inflammatory reliever therapy (AIR) or maintenance and reliever therapy (MART).

Special groups

  • Under 5s: diagnosis is difficult because objective tests are difficult and there are no good reference standards. Treat and review; attempt objective tests if still symptomatic at age 5.
  • Pregnancy: arrange asthma review in early pregnancy and postpartum; emphasise maintaining good control. Continue needed asthma medicines — SABA/LABA, ICS and oral theophyllines as normal; offer oral corticosteroids for exacerbations if needed; do not stop LTRA or LAMA if needed for symptom control.
  • Breastfeeding: use asthma medicines as normal in line with BNF.

6. SCA Consultation Essentials

  • This commonly appears as: “I keep needing my blue inhaler”, “my child wheezes at night”, “my asthma is not controlled”, or “I do not understand my new inhaler”.
  • Gather the pattern: daytime symptoms, night waking, exercise limitation, time off school/work, reliever use, oral corticosteroid courses, emergency attendances, triggers, smoking or vaping exposure, occupation, pets, damp or mould, and medication triggers.
  • Do not simply ask, “Are you using your inhaler?” Ask the patient to show you. Watch the technique, including spacer use if relevant. Check the prescription record for over-ordering relievers and under-collecting anti-inflammatory treatment.
  • Explain the plan in roles, not colours: “This medicine reduces airway inflammation,” “this one relieves symptoms,” or “this single inhaler is used both every day and when symptoms break through,” depending on the regimen.
  • Involve the patient safely: preferences and device ability matter, but do not compromise on anti-inflammatory treatment when asthma is diagnosed.
  • Make the safety-net specific: worsening breathlessness, symptoms not relieved by the agreed reliever plan, needing reliever more often, night waking, or any attack should trigger urgent advice or review according to the action plan.

7. Red Flags / Escalation / Referral

  • Features suggesting acute severe or life-threatening asthma: inability to complete sentences, oxygen saturation below 92%, silent chest, cyanosis, poor respiratory effort, exhaustion, drowsiness, confusion, hypotension, or very low peak expiratory flow where measured.
  • Life-threatening asthma: give emergency treatment while arranging immediate emergency transfer to hospital.
  • Acute severe asthma: initiate treatment and arrange urgent hospital referral/admission, especially if features persist after initial treatment, response is poor, there is previous near-fatal asthma, pregnancy, night presentation, concerning history or social concern.
  • Do not manage suspected severe or life-threatening exacerbation as routine asthma review.
  • Refer suspected occupational asthma to an occupational lung disease service or asthma specialist, ideally to be seen within 6 weeks. If occupational asthma is confirmed, explain that the best chance of improved control comes from early and complete removal from exposure to the cause.
  • Refer to specialist asthma care if: there is diagnostic uncertainty, persistent symptoms or exacerbations despite good adherence to optimised ICS-containing treatment for 3–6 months, severe or difficult-to-treat asthma, near-fatal asthma history, suspected asthma/COPD overlap with uncertainty, or uncontrolled asthma on high-dose ICS treatment.
  • Children under 5 not responding to initial treatment after checking technique, adherence, environment and alternative diagnoses need specialist assessment. A preschool child with hospital admission, or 2 or more emergency department admissions with wheeze in 12 months, should be referred to a specialist respiratory paediatrician.
  • Also consider specialist referral for a child with asthma plus food allergy or anaphylaxis, or significant adverse effects from asthma treatment such as faltering growth.

8. What the GP Should Do Today

  • Assess symptom pattern, control, risk, triggers, comorbidities, occupational link and current medicines.
  • Examine if symptomatic or diagnosis is uncertain. Include chest examination and observations if unwell.
  • Arrange objective testing according to age and availability. Do not permanently code confirmed asthma until clinical history and objective support align.
  • If asthma is confirmed or strongly suspected and treatment is needed, choose treatment by age band and symptom severity.
  • For age 12 and over with newly diagnosed asthma, offer low-dose ICS/formoterol as-needed anti-inflammatory reliever therapy (AIR). If highly symptomatic (e.g., regular night waking) or presenting with severe exacerbation, use low-dose maintenance and reliever therapy (MART) and treat acute symptoms as indicated.
  • For children aged 5–11, initial treatment is twice-daily paediatric low-dose ICS plus short-acting beta-2 agonist (SABA) as needed.
  • For under-5s with suspected asthma needing maintenance treatment, consider an 8–12 week trial of twice-daily paediatric low-dose ICS with SABA reliever.
    • If symptoms resolve, consider stopping ICS and SABA and review again after a further 3 months.
    • If symptoms recur by that review, or there is an acute episode needing systemic corticosteroids/hospitalisation, restart regular paediatric low-dose ICS with SABA as needed and titrate if needed.
    • If symptoms do not resolve during the trial, check inhaler technique, adherence, environmental sources and alternative diagnoses; refer if these do not explain non-response.
  • At every asthma-related contact: observe inhaler technique, check adherence, check the action plan, and ask about reliever use.
  • After any exacerbation, arrange primary-care review within 2 working days.

9. Practical Use in GP: How to Apply This Topic

Before prescribing or changing treatment

  • Confirm age band and current regimen.
  • Check whether the patient can use the device.
  • Check adherence using prescription records.
  • Check reliever overuse and anti-inflammatory underuse.
  • Check triggers, occupational exposure, smoking, vaping, damp, mould and comorbidities.

Starting / advising

  • Explain whether the inhaler is anti-inflammatory reliever therapy, maintenance and reliever therapy, a daily preventer, or a separate reliever.
  • Give information on what the inhaler contains, how it works, when to take it and how to use the device.
  • Use the lowest inhaled corticosteroid dose that obtains asthma control.

Patient instructions

  • Bring inhalers and spacer to reviews.
  • Return used or expired inhalers to a pharmacy.
  • Do not rely on shaking, weighing, floating or using an inhaler until it stops actuating to know whether active doses remain.
  • If using a pressurised metered-dose inhaler (pMDI), a spacer should usually be prescribed, particularly in children.
  • For pMDIs, remove the mouthpiece cover fully, check inside and outside the mouthpiece are clear and undamaged before use, and store the inhaler with the cover on. If more than one inhaler is needed, prescribe the same type of device where possible to reduce technique errors.

Spacer safety

  • The spacer must be compatible with the inhaler.
  • Spacers should not be treated as interchangeable.
  • Wash monthly in detergent, allow to air dry, and replace every 6–12 months.

Nebuliser safety

  • In children and adolescents, home nebuliser use for acute asthma rescue should only be initiated and managed by asthma specialists. Advise urgent medical attention if worsening symptoms are not relieved by prescribed rescue medication, even if there is short-term recovery.

Review / monitoring

  • Review at least annually and after any exacerbation.
  • Review 8–12 weeks after starting, stepping up, changing or reducing treatment.
  • At review, actively flag risk of poor outcomes: non-adherence, more than 2 SABA inhalers in a year, 2 or more oral corticosteroid courses in a year, 2 or more ED attendances, or any hospital admission for asthma.
  • In children, monitor growth at least annually.
  • In adults, consider FeNO monitoring at regular review and before and after changing therapy.

Escalate / change if:

  • The patient cannot use the device after repeated training.
  • Reliever use is rising.
  • Control remains poor despite good adherence and technique.
  • There is diagnostic doubt, occupational suspicion or severe-risk history.

10. Medicines, Investigations and Intervention Safety

Inhaled corticosteroids (ICS)

Examples include beclometasone, budesonide, ciclesonide, fluticasone and mometasone. They are central to asthma anti-inflammatory treatment. Oral candidiasis and voice effects are relevant; spacer use and mouth rinsing after inhaled corticosteroid doses may reduce local adverse effects. Children on prolonged inhaled corticosteroids need annual height and weight monitoring.

Inhaled corticosteroid/formoterol combinations

Anti-inflammatory reliever therapy (AIR) uses a reliever inhaler containing an ICS and formoterol. Maintenance and reliever therapy (MART) uses a single ICS/formoterol inhaler for daily maintenance and symptom relief. Only specific ICS/formoterol inhalers are licensed for AIR or MART, and licensing varies by product, dose, device and age. NICE states that, in November 2025, as-needed AIR therapy in mild asthma was licensed only for certain budesonide/formoterol inhalers, and only one budesonide/formoterol dry powder inhaler 100 micrograms/6 micrograms per inhalation was licensed for MART in children aged 6–11; other ICS/formoterol MART use in children under 12 may be off-label. Non-formoterol LABA combinations are not licensed for AIR or MART. Check the BNF or Summary of Product Characteristics before prescribing.

Short-acting beta-2 agonists (SABA)

Salbutamol and terbutaline are named examples. SABA overuse is associated with increased risk of severe exacerbations, hospitalisation and mortality. Review patients using as-needed SABA more than twice weekly, requesting more reliever prescriptions, or failing to collect anti-inflammatory treatment.

Montelukast

Montelukast is an oral leukotriene receptor antagonist (LTRA). It may be used as add-on treatment in selected pathways and is trialled for 8–12 weeks where specified. Counsel about neuropsychiatric reactions: new or worsening mood, sleep or behaviour changes, nightmares, aggression, anxiety, depression or thoughts of self-injury. Stop montelukast and seek immediate medical attention if suspected.

Long-acting muscarinic receptor antagonist (LAMA)

Tiotropium, including Spiriva Respimat, is named as an add-on option in people aged 12 and over in selected uncontrolled asthma pathways. Cautions include bladder outflow obstruction, prostatic hyperplasia, susceptibility to angle-closure glaucoma, paradoxical bronchospasm and specified recent serious cardiovascular disease.

Beta-blockers

Beta-blockers, including eye drops, are contraindicated or usually avoided in asthma because of bronchospasm risk. If there is no alternative, cardioselective beta-blocker use should be cautious and under specialist supervision.

Beclometasone potency trap

Qvar and Clenil Modulite are not interchangeable. Qvar is extra-fine and approximately twice as potent as Clenil Modulite. Prescribe beclometasone inhalers by brand where potency differences matter.

Investigations

FeNO, blood eosinophils, bronchodilator reversibility with spirometry and peak expiratory flow (PEF) variability change diagnosis. Regular peak expiratory flow monitoring is not recommended for routine control assessment unless there is a person-specific reason, such as inclusion in the action plan.

11. How to Explain It to the Patient

“Your symptoms fit asthma, but we should not confirm the diagnosis from symptoms alone; we need breathing or inflammation tests to support it.”

“Your reliever use tells us something important: needing it more often can mean the asthma is not controlled, even if it helps for a short time.”

“A blue reliever inhaler should not be the only asthma treatment; asthma also needs anti-inflammatory treatment to reduce the risk of attacks.”

“Please show me exactly how you use the inhaler, because technique problems are common and can look like treatment failure.”

“Your action plan should tell you what to do when symptoms start changing, when to increase treatment, and when to seek urgent help.”

“If montelukast affects mood, sleep or behaviour, stop it and seek medical advice immediately.”

12. When the Plan Changes

If symptoms are variable but objective tests do not support asthma

  • Why this changes the plan: asthma should not be confirmed without objective support.
  • What the GP does now: keep suspected asthma coding, consider alternative diagnoses and arrange further testing or referral if suspicion remains.

If a patient aged 12 or over is using short-acting beta-2 agonist alone

  • Why this changes the plan: reliever-only treatment is unsafe in asthma.
  • What the GP does now: change to an inhaled corticosteroid-containing regimen, usually as-needed anti-inflammatory reliever therapy (AIR) if appropriate.

If asthma remains uncontrolled despite age-appropriate treatment

  • If a person aged 12 years or over remains uncontrolled on moderate-dose MART despite good adherence, check FeNO if available and blood eosinophils; refer to specialist asthma care if either is raised. If neither is raised, consider an 8–12 week trial of an LTRA or LAMA added to moderate-dose MART; refer if asthma remains uncontrolled despite moderate-dose MART and trials of both LTRA and LAMA.
  • In children aged 5–11 who remain uncontrolled on twice-daily paediatric low-dose ICS plus SABA as needed, consider paediatric low-dose MART if the child can manage the regimen. If MART is unsuitable, use the conventional pathway: consider an LTRA trial for 8–12 weeks and stop it if ineffective, then progress to paediatric low-dose and then moderate-dose ICS/LABA plus SABA as needed. Refer if still uncontrolled on paediatric moderate-dose MART or paediatric moderate-dose ICS/LABA maintenance treatment, with or without LTRA depending on response.

If symptoms improve away from work or on holiday

  • Why this changes the plan: occupational asthma becomes possible.
  • What the GP does now: record the occupational pattern and refer to an occupational lung disease service or asthma specialist.

If a child under 5 does not respond to the initial treatment trial

  • Why this changes the plan: diagnosis is uncertain and alternative causes are common.
  • What the GP does now: check technique, adherence, environmental sources and alternative diagnoses; refer if these do not explain non-response.

13. Common AKT / SCA Traps

  • Confirming asthma without objective testing.
  • Assuming normal examination excludes asthma.
  • Using adult fractional exhaled nitric oxide (FeNO) thresholds in children.
  • Prescribing short-acting beta-2 agonist without inhaled corticosteroid.
  • Escalating treatment before checking technique and adherence.
  • Missing occupational asthma by not asking about symptoms away from work.
  • Treating all inhaled corticosteroid/formoterol inhalers as interchangeable for anti-inflammatory reliever therapy or maintenance and reliever therapy.
  • Forgetting montelukast neuropsychiatric counselling and stop advice.

14. Common Exam Angles

  • Angle: Adult with cough, wheeze and normal examination.
    • Hidden challenge: symptoms suggest asthma but diagnosis still needs objective support.
    • What the candidate must not miss: code as suspected asthma until confirmed.
  • Angle: Teenager using a blue inhaler several days per week.
    • Hidden challenge: reliever overuse and possible lack of anti-inflammatory treatment.
    • What the candidate must not miss: short-acting beta-2 agonist should not be prescribed alone.
  • Angle: Child with poor control despite “taking inhalers”.
    • Hidden challenge: device ability, spacer use, adherence and technique.
    • What the candidate must not miss: observe technique before stepping up.
  • Angle: Baker with adult-onset asthma symptoms better on holiday.
    • Hidden challenge: occupational asthma.
    • What the candidate must not miss: referral to occupational lung disease service or asthma specialist.

15. 90 Second Audio Summary Script

Asthma in primary care is not just “wheeze equals asthma”. The exam wants you to remember that asthma diagnosis needs a suggestive clinical history plus objective support. Symptoms are variable: wheeze, cough, chest tightness and breathlessness may be worse at night, early morning, seasonally, with exercise, viral infections or irritants. A normal chest exam does not rule it out.

For adults, fractional exhaled nitric oxide of 50 parts per billion or more, or eosinophils above the lab range, supports diagnosis. For children aged 5 to 16, fractional exhaled nitric oxide of 35 or more supports diagnosis. Bronchodilator reversibility and peak flow variability are the next key tests. If child tests remain non-confirmatory but suspicion persists, house dust mite sensitisation or raised total IgE plus eosinophils above 0.5 × 10⁹/L can change the answer.

Management is age-based. From age 12, new asthma usually starts with an inhaled corticosteroid/formoterol anti-inflammatory reliever; if highly symptomatic or uncontrolled, maintenance and reliever therapy is used. Children 5 to 11 usually start with twice-daily paediatric low-dose inhaled corticosteroid plus a short-acting beta-2 agonist as needed, and have a separate uncontrolled-asthma pathway. Under 5s may have an 8–12 week treatment trial with outcome-based review.

Never prescribe short-acting beta-2 agonist alone in asthma. Check inhaler technique and adherence before stepping up. Flag risk if there is non-adherence, more than 2 SABA inhalers per year, 2 or more steroid courses, 2 or more emergency attendances, or any hospital admission. Review at least annually, after attacks, and 8 to 12 weeks after treatment changes. Every patient needs a personalised action plan. Montelukast needs counselling about mood, sleep and behaviour changes. The biggest GP traps are missing poor control, missing occupational asthma, and treating inhalers as interchangeable when they are not.

References

Important Disclaimer

This MedDigest MRCGP Topic Essentials is an independent educational and revision resource, created to support exam preparation only. It is not a clinical guideline, prescribing resource, or a substitute for your own professional judgment.

This content is designed to highlight exam-relevant clinical principles, management pathways, and consultation approaches in a concise format. Any example explanations, consultation wording, scenario angles, or summary scripts are illustrative and should not be used as stand-alone clinical advice.

This resource has not been produced, reviewed, or endorsed by NICE, the Royal College of General Practitioners, or any other official organisation.

Medicine and guidance change over time. For definitive recommendations, always consult the latest official guidance, the BNF, and your local clinical policies and referral pathways.

MedDigest and its authors accept no responsibility for any loss, harm, or adverse outcome arising from reliance on the information contained in this resource.

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