Asthma: the end of the blue inhaler first

Clinical Rounds, the GPAtlas podcast. Respiratory. 18 minutes. Published 31 August 2026. Free to listen.

Clinical source: our own Ocean article "Asthma", last reviewed 23 November 2025.

Transcript

Sarah: Hello, and welcome to GPAtlas Clinical Rounds. I'm Sarah, and this is the podcast where we take one thing you'll genuinely see this week, and work out together what to do about it.

Ben: And I'm Ben. I'm the one who's been through the guidance, so when Sarah tells you what she did, I'll tell you whether the evidence agrees with her. Today, the asthma review, and why the one you did this morning was probably built on a guideline that no longer exists.

Sarah: So. Nineteen-year-old, comes in for her asthma review. She's on a brown preventer twice a day, and a blue inhaler she uses, she says, maybe three times a week. Sometimes before netball. She feels fine. Her peak flow's fine. And under the guideline I trained on, that's a reasonably well-controlled patient and a five-minute appointment. Except it isn't any more. Because using the blue one three times a week is now the finding, not the footnote.

Ben: Three things today. What actually changed in November twenty twenty-four. How you're now meant to diagnose it, which is the bit most of us skipped. And what to do with the patient in front of you, who is almost certainly on the wrong regime through no fault of yours.

Sarah: So what changed. For the first time, the British Thoracic Society, NICE and SIGN stopped publishing separate asthma guidelines and produced one together. And the headline is blunt. Treating asthma with a short-acting reliever alone is over. No more, here's your blue inhaler, come back if you're using it a lot. The reliever-only step at the bottom of the ladder has gone.

Ben: And the reasoning is worth knowing, because it changes how you explain it. A short-acting reliever treats the symptom and does nothing at all to the inflammation underneath. So every time she reaches for the blue one, she's getting relief and no treatment. And here's the number that should stop you. Three or more reliever inhalers a year, so roughly one a month, is a recognised marker of asthma death risk. Not a marker of poor control. Death risk. So when that request comes through on the repeats, it is never a re-issue. It is a review. The new principle is simple: every time she gets relief, she should also get a steroid.

Sarah: So that's the first thing. Reliever-only asthma treatment is finished. If someone leaves your room with a blue inhaler and nothing else, that is now the wrong answer.

Sarah: Now the diagnosis, and I'll be honest, this is the part I found hardest, because it asks for tests a lot of us don't have to hand. The guideline moves away from diagnosing asthma on a history and a peak flow diary. It wants objective evidence of eosinophilic inflammation, first.

Ben: In practice that means the first-line tests are a fractional exhaled nitric oxide, the FeNO, or a blood eosinophil count. And the point people miss is that these are diagnostic, not just supportive: a raised FeNO or an eosinophil count above the lab's normal range confirms asthma in someone with the right symptoms. You don't then need to prove reversibility as well. Spirometry and peak flow variability come after, when the first tests don't settle it.

Sarah: And practically, if you haven't got a FeNO machine, and plenty of us haven't, the blood eosinophil count is the accessible one. Most of our patients have had a full blood count in the last couple of years. It's already on the screen. Which is worth remembering before you order anything: the answer may already be in the record.

Sarah: Recap. Diagnose on inflammation, not just on symptoms. FeNO or eosinophils first, and the eosinophil count you may already have.

Sarah: And what do I do with her, the nineteen-year-old in front of me? She comes off the blue- inhaler-plus-brown-preventer model entirely. The new starting point is a combined inhaler containing a steroid and formoterol, and she uses it when she needs it. That's called AIR, anti-inflammatory reliever. So when she reaches for something before netball, the thing she reaches for is treating her, not just opening her airways.

Ben: And if she needs more than that, the next step isn't a bigger preventer plus a separate reliever. It's MART, maintenance and reliever therapy: the same combined inhaler taken regularly and used for relief on top. One inhaler doing both jobs. Which, incidentally, solves the oldest problem in asthma care, that people are diligent with the reliever and forgetful with the preventer. Now they're the same device.

Sarah: So: one inhaler, with a steroid in it, used when she needs it. Not two inhalers with different jobs.

Sarah: So let's do the review itself, because that's where most of us meet this. She's in front of me, she says she's fine, and I need to know whether that's true. There are four questions that settle it. Is she needing her reliever three or more days a week. Is she waking at night once a week or more. Is anything she wants to do being limited by her chest. And has she had any course of oral steroids, or any attack at all, in the last year. Any one of those is poor control. Not borderline. Poor.

Ben: And there's a fifth thing, which isn't a question you ask, it's a number you look up before she comes in. How many reliever inhalers has she had in the last twelve months. Three or more a year, which is roughly one a month, is described in our article as a recognised marker of asthma death risk, and it says never simply re-issue. That phrase is doing a lot of work. It means the repeat request itself is the clinical event. It featured repeatedly in the National Review of Asthma Deaths.

Sarah: And then the thing I have to stop myself doing, which is jumping straight to a step up. Our article is explicit that you address the treatable reasons for poor control first. Adherence. Inhaler technique. Smoking and vaping. Triggers. Comorbidity. Before you step up. And there's a line in there I've started quoting to trainees, that correct technique and a spacer with any metered dose inhaler often achieve more than a step up in therapy. The highest-yield thing you can do in that ten minutes is watch her actually use it.

Ben: Three relievers a year is not a repeat request. It is a warning.

Ben: Two traps in the diagnosis that are worth more than they look. The first is that both FeNO and spirometric reversibility are suppressed by inhaled steroids and by smoking. So results are far more likely to read normal once treatment has started. Which means a normal test in a treated or smoking patient does not exclude asthma. If you've already started her on a preventer and then send her for tests to prove the diagnosis, you may have made the diagnosis unprovable. Test first where you can.

Ben: The second runs the other way. A raised FeNO at review, in someone whose asthma is uncontrolled, often points to poor adherence or a need for more inhaled steroid. So it isn't automatically a signal to escalate the regime. It may be telling you the regime she has isn't reaching her lungs. Same number, two completely different actions.

Sarah: And the prescribing trap, which I think is the single most dangerous one on this list. If you are going to use a combination inhaler as the reliever, the reliever component has to contain formoterol, because it's the fast-onset one. A fixed combination with salmeterol, so Seretide, or vilanterol, so Relvar Ellipta, is maintenance only. It must never be used as a reliever and never for MART. If you write MART on a Relvar prescription, you have given somebody an inhaler that will not open their airway when they need it opened.

Ben: If it is the reliever, it contains formoterol. No exceptions.

Sarah: Now the attack, because the numbers matter and they're the ones you want in your head rather than on a screen. Moderate: salbutamol, four to ten puffs through a spacer, one puff every thirty to sixty seconds, and you repeat that every ten to twenty minutes. Severe or life-threatening: nebulised salbutamol five milligrams, oxygen-driven, back to back, plus ipratropium five hundred micrograms. And prednisolone, forty to fifty milligrams orally, as early as you can, continued for at least five days or until recovery. And you tell them to keep taking it even when they feel better, because that's exactly when people stop.

Ben: And two things not to do. Don't prescribe antibiotics routinely, because most exacerbations are viral. Reserve them for clear evidence of bacterial infection. And don't be reassured by the wrong signs. As an attack worsens, airflow can fall so low that the wheeze disappears. Our article calls a silent chest, exhaustion, or a falling respiratory effort pre-terminal signs, not reassurance. Same for the blood gas: a normal or rising carbon dioxide in a tiring asthmatic signals near-fatal asthma. You escalate on those, even when the patient looks deceptively calm.

Sarah: And then the bit that gets dropped when the surgery is busy and the crisis has passed. Review within two working days. Recheck the technique, recheck adherence, issue or update the action plan, and make sure she's actually on inhaled steroid treatment going forward. That forty-eight hour review is not administrative. It's the window where you stop the next one.

Ben: A quiet chest is not a better chest. And review within two working days.

Sarah: Three quick ones to finish, all of which have changed how I consult. Montelukast. The MHRA warning is real and the numbers are worth knowing so you can counsel properly: sleep disturbance, depression, agitation or aggression in up to about one in a hundred, attention or memory problems around one in a thousand, and rarely hallucinations or suicidal thinking, about one in ten thousand. Newly recognised are stuttering and obsessive compulsive symptoms. If new or worsening neuropsychiatric symptoms develop, you stop it. And you tell the family what to watch for when you start it, not after.

Sarah: Occupational asthma. Suspect it when symptoms improve on days away from work or on holiday. That one question, does it get better when you're off, is the whole screen. Then a peak flow diary covering work days and non-work days, and a referral to an occupational asthma specialist. And pregnancy, which people get wrong out of caution: uncontrolled asthma is more dangerous to the fetus than asthma medicines are. You continue the preventer, the long-acting and the reliever, and you treat an acute attack as vigorously as you would in anybody else.

Ben: And children are not small adults here, which is the thing to take away if you see a lot of them. A five to eleven year old does not start on the adult AIR pathway. They start on regular twice-daily paediatric low-dose inhaled steroid plus a reliever as needed, always with a spacer. Under-fives get an eight-week trial of paediatric low-dose steroid, and if symptoms resolve and then recur, you restart it as maintenance. And the paediatric referral trigger to hold on to: an admission, or two or more emergency department visits for wheeze in twelve months.

Sarah: Does it get better when you are off work? One question.

Ben: One more piece of false reassurance, and it's the commonest of the lot. A normal chest examination is common in stable asthma and never rules it out. Listening to a well patient in clinic tells you almost nothing about what happens to them at four in the morning. So the history and the numbers carry the diagnosis, not the stethoscope.

Sarah: And the things around the edges that actually shift control, which I used to treat as afterthoughts. Weight, where our article says loss improves symptom control and reduces exacerbations. Coexisting dysfunctional breathing, which is worth a breathing retraining referral rather than another inhaler. Annual flu and covid vaccination. And bone health, because somebody having frequent courses of oral steroids warrants attention to fracture risk and osteoporosis prevention. That last one almost never gets done, and it's usually us who should be doing it.

Ben: And practically, for the patient already on an older regime, the conversion is written down. Uncontrolled on a fixed inhaled steroid and long-acting combination, with or without montelukast, plus a separate reliever, means you consider moving to moderate-dose MART. You don't have to wait for them to deteriorate to make that change. The review is the opportunity.

Sarah: A normal chest in clinic tells you nothing about four in the morning.

Sarah: And one closing thought about the reliever count, because it's the most actionable thing in this episode. Three or more a year is described in our article as a recognised marker of asthma death risk, with the instruction never simply to re-issue.

Sarah: Which makes it a searchable list rather than a thing to remember. Everyone on your asthma register who's had three or more reliever inhalers in twelve months. That's a query, it takes minutes, and every name on it is someone whose next repeat request should trigger a review instead of a signature.

Ben: It is a search, not a memory. Three or more in twelve months.

Ben: Right, exam corner. Sarah, and everybody driving, a few seconds. Twenty-four year old woman, new cough and wheeze on exertion for three months, no smoking history. Her blood eosinophil count is clearly above the lab reference range. What does the current guidance say you should do next? A, arrange spirometry with reversibility before making the diagnosis. B, diagnose asthma and start treatment. C, trial a short-acting reliever and review in four weeks. Or D, arrange peak flow variability monitoring for two weeks.

Ben: It's B. In someone with that history, the raised eosinophil count is diagnostic, and you treat. A is the old reflex and it delays her by weeks for a test that will not change your mind. C is the practice the guideline specifically abandoned, and it leaves her inflammation untreated in the meantime. And D, peak flow variability, is still in the guideline but it sits later, for when the first-line tests haven't given you an answer.

Sarah: So. Three things for Monday. One. Nobody leaves with a reliever alone. If it's the only inhaler on the prescription, the prescription is wrong. Two. Diagnose on inflammation. FeNO or an eosinophil count, and check the record before you order anything, because it may already be there. And three. Your next asthma review is a chance to move somebody off the old model. You do not have to wait for them to deteriorate to change it.

Sarah: One thing to reflect on, if you're logging this. Think about your asthma register. How many of those patients are on a preventer and a separate reliever, right now, today? The full transcript and the references are on the episode page. Ben and I are synthetic voices. The medicine isn't. See you next week.

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