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Asthma is a common, long-term condition where the airways become inflamed and twitchy, narrowing in response to triggers such as allergens, exercise, cold air or infection. This causes wheeze, cough, chest tightness and breathlessness that tend to come and go. Most people control it well with inhalers — a "preventer" to calm the inflammation and a "reliever" for symptoms — plus avoiding known triggers. Good inhaler technique and a written action plan are key to staying well and avoiding attacks. This page covers what asthma is, how it is diagnosed and how it is managed.
Definition
Asthma is a heterogeneous chronic inflammatory airway disease characterised by variable expiratory airflow limitation and a history of respiratory symptoms (wheeze, breathlessness, chest tightness, cough) that vary over time and in intensity.1
Pathophysiology
Asthma involves airway inflammation (most commonly eosinophilic, type 2/Th2-mediated), bronchial hyperresponsiveness, airflow limitation (initially reversible) and, in some patients, airway remodelling with persistent airflow obstruction. Several phenotypes are recognised, including allergic, non-allergic, late-onset, eosinophilic, and obesity-related asthma.
Co-morbidities
Common co-morbidities include allergic rhinitis, chronic rhinosinusitis with nasal polyps, gastro-oesophageal reflux, obstructive sleep apnoea, obesity, anxiety and depression, vocal cord dysfunction, dysfunctional breathing, and aspirin-exacerbated respiratory disease (AERD).
Prevalence
Approximately 1 in 9 Australians (around 2.7 million people) have asthma. Prevalence is higher in Aboriginal and Torres Strait Islander people, in whom asthma-related morbidity and mortality are also higher. Despite effective treatments, asthma deaths still occur and most are considered preventable.
Causes and triggers
Risk factors include atopy, family history, environmental allergens (house dust mite, animal dander, pollens, moulds), respiratory viral infections (particularly RSV in infancy), tobacco smoke (including in-utero exposure), air pollution, occupational exposures, and obesity. Common triggers for exacerbation include viral upper respiratory infections, allergens, exercise, cold air, smoke, and certain medications (NSAIDs, beta-blockers).2
Symptoms
The classic symptoms are wheeze, breathlessness, chest tightness, and cough — particularly when they are episodic, variable, worse at night or early morning, and triggered by recognised stimuli. Children may present with recurrent cough or exercise intolerance without overt wheeze.
Phenotypes and severe asthma
Recognising phenotype guides treatment. Type 2-high asthma (eosinophilic, allergic) is responsive to inhaled corticosteroids and to biologics targeting IgE, IL-5, IL-5R, IL-4Rα, and TSLP. Type 2-low asthma may be less corticosteroid-responsive. Severe asthma — uncontrolled despite high-dose ICS/LABA with good adherence and inhaler technique — warrants specialist review and biologic consideration.3
Diagnosis
Importance of a diagnosis
A correct asthma diagnosis avoids both under-treatment (with risk of severe exacerbation and death) and over-treatment (with corticosteroid exposure when symptoms are due to another condition). Objective confirmation of variable airflow limitation is recommended in all patients where possible.
How is it diagnosed?
Diagnosis is based on a typical pattern of symptoms plus objective evidence of variable expiratory airflow limitation. Objective evidence may come from spirometry with bronchodilator reversibility, peak expiratory flow variability, exercise challenge, or bronchial provocation testing.4
Lung function
Spirometry typically shows airflow obstruction — an FEV1/FVC ratio below the lower limit of normal, a z-score under −1.65 — that improves after a bronchodilator. Peak flow variability >10% (adults) or >13% (children) over two weeks is supportive. Normal spirometry between episodes does not exclude asthma.
Two definitions of bronchodilator responsiveness are in circulation, and they are not interchangeable. The TSANZ Technical Standards for Spirometry in Australian Primary Care (SPC01, 2026) define responsiveness as an increase of >10% of the predicted value in FEV1 or FVC, and state that the older methods based on change from the patient's own baseline — the familiar ≥12% and ≥200 mL — are no longer recommended for this purpose.5 The legacy rule is still widely quoted and is still printed by many spirometers, so it is worth checking which definition a report has applied before drawing a conclusion from it. Full detail is on the spirometry guide.
Fractional exhaled nitric oxide (FeNO)
FeNO is a non-invasive marker of eosinophilic airway inflammation. Elevated FeNO supports a diagnosis of type 2-high asthma and predicts corticosteroid responsiveness. It is also useful for monitoring adherence and inflammation in known asthma.
Sputum and biomarkers
Induced sputum eosinophil counts identify eosinophilic asthma and are used in specialised centres to guide treatment. Blood eosinophil count is a more accessible surrogate that, alongside FeNO and serum IgE, guides selection of biologic therapy in severe asthma.
Allergy assessment
Atopic status is identified by skin prick testing or specific IgE. Identifying clinically relevant aeroallergens supports environmental control strategies and decisions around allergen immunotherapy and biologic therapy.
Management
Management and goals
The goals of asthma management are: good symptom control (minimal daytime and night symptoms, no activity limitation), no severe exacerbations, normal or near-normal lung function, no medication side-effects, and personal goals (e.g. sport, work, sleep).
Treatment options
Treatment is delivered in a stepwise fashion (Australian Asthma Handbook steps). Key principles include:
- ICS-containing therapy in all adults and adolescents (SABA-only treatment is no longer recommended).
- Combined ICS/formoterol used as both maintenance and reliever (MART/AIR) in selected patients.
- Stepwise increase in ICS dose and addition of a LABA as required.
- LAMA add-on for poorly controlled disease.
- Biologic therapy for severe asthma based on phenotype.
- Allergen immunotherapy in selected patients.
- Smoking cessation and trigger avoidance.
- Inhaler technique and adherence as core, ongoing interventions.6
Identifying an exacerbation
An exacerbation is a progressive deterioration in symptoms over hours to days, with increased breathlessness, wheeze, cough or chest tightness, increased reliever use, falling peak flow, and reduced response to reliever therapy. Severe exacerbations may present with inability to complete sentences, accessory muscle use, tachycardia, and hypoxaemia.
Asthma action plan
Every patient should have a written asthma action plan tailored to their reliever and preventer regimen. It defines green (well), yellow (worsening symptoms — what to do), and red (severe — emergency action) zones, including when and how much oral corticosteroid to commence, and when to call an ambulance.
Medications
Medications for asthma
Medications are divided into preventers (inhaled corticosteroids, ICS/LABA combinations, LAMA, leukotriene receptor antagonists, biologics), relievers (short-acting beta-agonists, ICS/formoterol as anti-inflammatory reliever), and oral corticosteroids for exacerbations. Biologic options in Australia include omalizumab, mepolizumab, benralizumab, dupilumab and tezepelumab.
Correct use of medications
Inhaler technique is one of the most important determinants of asthma control. Up to 70–90% of patients use their inhaler incorrectly. Device selection, written and demonstrated technique, and review at every encounter are essential. A spacer should be used with pressurised metered-dose inhalers in most patients.7
Order of medications
For routine maintenance therapy, preventer doses are taken at consistent times each day. When multiple devices are used, the recommended order is:
- Reliever (e.g. salbutamol) if symptomatic — used to relieve airflow obstruction first
- Preventer (ICS or ICS/LABA)
- Rinse mouth and spit after ICS to reduce oral candidiasis and dysphonia
Multi-system manifestations
Allergic rhinitis and rhinosinusitis
Upper and lower airway disease frequently co-exist (“one airway, one disease”). Treating allergic rhinitis and chronic rhinosinusitis improves asthma control. Intranasal corticosteroids, saline irrigation, antihistamines, and ENT referral when appropriate are mainstays of management.
GORD
Reflux can trigger or worsen asthma in some patients. Lifestyle measures and proton pump inhibitors may be considered when reflux symptoms are present; routine PPI treatment in the absence of symptoms is not recommended.
OSA and dysfunctional breathing
Untreated OSA worsens asthma control and is more prevalent in this population. Screening (e.g. STOP-Bang) and referral for sleep study should be considered. Dysfunctional breathing and vocal cord dysfunction often mimic or coexist with asthma; physiotherapy-led breathing retraining and speech pathology can be highly effective.
Anxiety and depression
Anxiety and depression are common, contribute to poorer control and adherence, and increase exacerbation risk. Screening and integrated psychological support should be part of routine care.
Living with asthma
Nutrition
A balanced diet rich in fruit, vegetables and oily fish is associated with better asthma outcomes. Obesity is a treatable contributor; weight loss in obese adults improves asthma control. Specific food triggers should be considered when there is a consistent history but routine elimination diets are not recommended.
Sleep
Nocturnal or early-morning symptoms suggest suboptimal control. Sleep should be reviewed at every visit and OSA screened for, particularly in adults with snoring, witnessed apnoeas, daytime sleepiness, or obesity.
Travel
Patients should carry their action plan, reliever (and spacer), preventer, and a course of oral corticosteroid (where appropriate) when travelling. Air travel is safe for most patients; in-flight oxygen assessment is rarely required. Triggers at the destination (allergens, altitude, air quality) should be considered.
Prognosis
Most people with asthma can achieve good symptom control and normal life expectancy with appropriate treatment. Risk factors for poor outcomes include severe asthma, frequent oral corticosteroid use, prior intubation or ICU admission, non-adherence, smoking, and significant co-morbidity.
Anxiety, depression and stigma
Many patients experience anxiety around their condition, particularly after a near-fatal event. Open discussion, robust action plans, and psychological support reduce this burden. Adolescents and young adults benefit from targeted support to maintain adherence during life transitions.
Role of the physiotherapist
While medical therapy controls the underlying inflammation, the physiotherapist adds value where breathing mechanics and fitness are involved. They deliver breathing retraining for dysfunctional breathing and vocal-cord dysfunction that commonly coexist with asthma, check and correct inhaler technique, and support exercise and weight management. They also help distinguish exercise-induced symptoms from deconditioning and coach confident, active living.8,9
Warning signs
Part 1 · References
- Global Initiative for Asthma. Global strategy for asthma management and prevention: 2026 update. GINA, 2026.
- Parsons JP, Hallstrand TS, Mastronarde JG, et al. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med 2013;187(9):1016–1027.
- Chung KF, Wenzel SE, Brozek JL, et al. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J 2014;43(2):343–373.
- National Asthma Council Australia. Australian Asthma Handbook, version 3.0. Melbourne: National Asthma Council Australia, 2025.
- Thoracic Society of Australia and New Zealand. SPC01: TSANZ Technical Standards for Spirometry in Australian Primary Care. TSANZ; 2026.
- Reddel HK, Bacharier LB, Bateman ED, et al. Global Initiative for Asthma strategy 2021: executive summary and rationale for key changes. Eur Respir J 2022;59(1):2102730.
- Usmani OS, Lavorini F, Marshall J, et al. Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes. Respir Res 2018;19(1):10.
- Santino TA, Chaves GSS, Freitas DA, Fregonezi GAF, Mendonça KMPP. Breathing exercises for adults with asthma. Cochrane Database Syst Rev 2020;3:CD001277.
- Carson KV, Chandratilleke MG, Picot J, Brinn MP, Esterman AJ, Smith BJ. Physical training for asthma. Cochrane Database Syst Rev 2013;(9):CD001116.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Supervised exercise, breathing technique and self-management education are the mainstay of cardiorespiratory physiotherapy for this condition.
Clinical evidence
Part 1 covers the same condition without the technical detail. What follows is the evidence base behind it, written for clinicians — the literature, the reasoning and the gaps.
For clinicians: this summary supports clinical reasoning and is not a protocol. Check current guidelines and local policy before applying it, and read it alongside the key references and guidelines directory.
Framing. Control is defined, staged and escalated pharmacologically under GINA1 and the Australian Asthma Handbook2; the physiotherapy contribution lies in breathing pattern, deconditioning, comorbid dysfunctional breathing and adherence — none of which respond to escalating inhaled therapy. Distinguishing uncontrolled asthma from asthma-plus-breathing-pattern-disorder is the single most useful clinical act, because the treatments diverge completely.
Breathing exercises
- A Cochrane review of breathing exercises in adults found improvements in quality of life, asthma symptoms and hyperventilation symptoms, with low-to-moderate certainty evidence and no signal of harm; effects on lung function are inconsistent.3
- Benefit appears largely mediated through reduced hyperventilation and improved symptom perception rather than changed airway calibre — consistent with the observation that symptom scores improve more than FEV1.
- No single technique (Papworth, Buteyko, yoga-derived pranayama, physiotherapy-taught diaphragmatic breathing) has established superiority; the common ingredient is slower, nasal, lower-volume tidal breathing with an unloaded upper chest.3
- Breathing retraining is an adjunct, never a substitute for inhaled corticosteroid therapy — a point worth stating explicitly to patients drawn to technique-only approaches.
Exercise, fitness and weight
- Physical training improves cardiorespiratory fitness and quality of life in people with asthma without worsening control, and is safe when the condition is reasonably controlled and a reliever strategy is in place.4
- Exercise-induced bronchoconstriction is managed by pre-exercise reliever, an adequate warm-up, and attention to environment (cold, dry, chlorinated or high-pollen air) — not by exercise avoidance.5
- In obesity-associated asthma, weight reduction improves symptoms and control independently of inhaled therapy; the physiotherapist's role sits in achievable activity progression alongside dietetic input.
Inhaler technique and adherence
- Critical inhaler errors are common and associated with worse control and increased exacerbation risk; technique degrades over time, so re-checking at review appointments matters more than one-off teaching.6
- Demonstrated technique and adherence must be confirmed before treatment is escalated or severe-asthma pathways — including biologic therapy — are considered, in line with the ERS/ATS severe-asthma guideline7 and current GINA strategy.8 See Getting Your Inhaler Technique Right.
Clinical reasoning
- Suspect a coexisting breathing pattern disorder where symptoms are disproportionate to spirometry, relief from reliever is poor, symptoms are positional or emotionally triggered, or the Nijmegen score is high — see Dysfunctional Breathing.
- Screen for the treatable overlaps that masquerade as poor control: rhinitis, GORD, OSA, obesity, anxiety and vocal-cord dysfunction.
- Objective before subjective: document spirometry with reversibility where available, and use consistent symptom measures over time rather than impressions.
Evidence gaps
- Optimal dose, delivery format and durability of breathing retraining are unresolved, as is which phenotype benefits most.
- Few trials isolate physiotherapy-delivered interventions from broader self-management packages.
- Little evidence guides breathing retraining in severe or biologic-treated asthma, or in children.
References for the clinical evidence summary
- Global Initiative for Asthma. Global strategy for asthma management and prevention: 2026 update. GINA, 2026.
- National Asthma Council Australia. Australian Asthma Handbook, version 3.0. Melbourne: National Asthma Council Australia, 2025.
- Santino TA, Chaves GSS, Freitas DA, Fregonezi GAF, Mendonça KMPP. Breathing exercises for adults with asthma. Cochrane Database Syst Rev 2020;3:CD001277.
- Carson KV, Chandratilleke MG, Picot J, Brinn MP, Esterman AJ, Smith BJ. Physical training for asthma. Cochrane Database Syst Rev 2013;(9):CD001116.
- Parsons JP, Hallstrand TS, Mastronarde JG, et al. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. Am J Respir Crit Care Med 2013;187(9):1016–1027.
- Usmani OS, Lavorini F, Marshall J, et al. Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes. Respir Res 2018;19(1):10.
- Chung KF, Wenzel SE, Brozek JL, et al. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Eur Respir J 2014;43(2):343–373.
- Reddel HK, Bacharier LB, Bateman ED, et al. Global Initiative for Asthma strategy 2021: executive summary and rationale for key changes. Eur Respir J 2022;59(1):2102730.
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