Asthma — what it is, and how we treat it today

In brief

• Asthma is a long-term inflammation of the airways that causes wheeze, breathlessness, chest tightness and cough.
• Every adolescent and adult with asthma should use an inhaled corticosteroid, even for mild symptoms; a blue reliever alone is no longer recommended.
• A budesonide-formoterol inhaler (Symbicort) can be both preventer and reliever, with fewer flare-ups than a reliever alone.
• Good inhaler technique, a written asthma action plan and a review at least twice a year make a large difference.
• Call 995 or go to A&E if you cannot speak in full sentences, your reliever isn’t working, or your lips turn blue.

We review asthma and check inhaler technique at our Punggol clinic. Book a chronic-care appointment.

What is asthma?

In asthma, the lung airways are inflamed and over-sensitive. Infections, allergens, exercise, cold air, irritants and sometimes stress make them tighten, swell and produce more mucus, so air is harder to push out. The classic symptoms are wheezing, shortness of breath, chest tightness and cough, often worse at night or early morning.

Around 5% of adults in Singapore have asthma. About 1 in 3 have had a flare-up needing unscheduled treatment in the past year, and roughly half have missed work or school. Singapore’s asthma admission rates are above the OECD average, largely because treatment is often underused or out of date.

Two things happen at once:

1. Chronic inflammation in the airway walls, present even when you feel fine. This needs long-term treatment.
2. Episodic tightening of the airway muscles (bronchoconstriction), causing acute symptoms. Quick-acting inhalers were designed for this.

The inflammation does not always match how you feel. Someone with few symptoms can still be at risk of a bad flare-up, so symptoms alone don’t show whether treatment is enough.

How we diagnose it

Asthma is usually diagnosed from your history (symptom pattern, triggers, response to an inhaler trial, family history, allergic tendency) and an examination. We often confirm it with:

• Spirometry: measures how much air you can blow out in the first second (FEV₁) and in total (FVC). Obstruction that improves after a reliever is typical of asthma.
• Peak expiratory flow (PEF): a home blow-meter. Readings over a few weeks support the diagnosis and guide monitoring.
• Blood eosinophil count: a finger-prick or venous blood test. A count above the laboratory reference range points to “type 2” (eosinophilic or allergic) asthma, which usually responds well to inhaled corticosteroid. It is not a test for asthma on its own: allergies, eczema, parasites and other conditions also raise it, and a normal count does not rule asthma out. With typical symptoms, a raised count can support the diagnosis when breathing tests are unavailable or normal, and it guides how strongly we start treatment.
• Response to a treatment trial: sometimes clear improvement on an inhaled corticosteroid is the diagnostic signal.
• Specialist tests: in uncertain cases we may refer to a respiratory specialist for bronchial challenge or fractional exhaled nitric oxide (FeNO) testing.

Other conditions can mimic asthma and need different treatment, especially in older adults: chronic obstructive pulmonary disease (COPD), post-viral cough, chronic rhinosinusitis with post-nasal drip, gastro-oesophageal reflux and heart failure.

The big shift — why we don’t treat asthma with a blue inhaler alone anymore

For decades, mild asthma was treated with a short-acting beta-agonist (SABA), usually salbutamol (Ventolin), used when breathless. Inhaled corticosteroid (“preventer”) was kept for more frequent symptoms. Strong evidence over the last decade has changed this:

• SABA alone does not treat the airway inflammation. You feel better briefly, but the inflammation and the risk of a bad flare-up remain.
• High SABA use is a marker of poor control. It is independently linked to more exacerbations, more emergency visits and more deaths.
• Locally, about one in three people admitted to ICU with a severe asthma attack were not on any preventer beforehand. Most of these admissions are preventable.
• Switching from SABA alone to an inhaled corticosteroid (ICS)-containing regimen cuts the risk of severe exacerbations by roughly 60%.

The current international guideline (GINA 2026) recommends that all adolescents and adults with asthma use an ICS-containing inhaler, even for mild or infrequent symptoms. SABA alone is no longer recommended for long-term management.

Asthma treatment is now anti-inflammatory first, symptom relief second. Treating only symptoms is not enough for most people and can make things worse over time. If you were last prescribed “just a blue inhaler”, or your plan is a few years old, it may need updating. We review it at every follow-up.

Preventers and relievers — and how modern inhalers combine both

Preventers (controllers)

These treat the inflammation. The mainstay is inhaled corticosteroid (ICS), delivered into the airway at a dose much smaller than oral steroids. Examples:

• Budesonide (Pulmicort)
• Fluticasone (Flixotide)
• Beclomethasone (Beclo-Asma)

ICS takes days to weeks of regular use to work fully. You won’t feel it working as you do a reliever, but the drop in flare-ups is large.

Relievers

Relievers open the airways by relaxing the muscle. The classic one is a short-acting beta-agonist (SABA), almost always salbutamol (Ventolin) in Singapore. It works in minutes and lasts 3–6 hours.

The modern combination — ICS-formoterol

Formoterol is a long-acting beta-agonist (LABA) that, unlike older LABAs such as salmeterol, also works quickly. So an ICS-formoterol inhaler can be both preventer and reliever. This is AIR (Anti-Inflammatory Reliever), or MART (Maintenance And Reliever Therapy) when also used daily.

At KTMC we use budesonide-formoterol (Symbicort), locally registered for patients aged 6 and older.

Every reliever puff also delivers anti-inflammatory treatment, so you can’t “over-rely on the reliever” as with salbutamol. Studies consistently show fewer exacerbations and hospital visits than with a SABA reliever, especially in people who miss daily preventer doses.

How we choose and step up treatment

The ACE Clinical Guideline and GINA both support a stepwise approach based on symptoms, flare-up risk and current treatment. Simplified, for adolescents and adults:

Key points:

• ICS-containing treatment is recommended at every step. There is no longer a “Step 1 = SABA only”.
• Step up if you still have frequent symptoms, night waking, exercise limitation or frequent reliever use.
• Step down once symptoms have been well controlled for at least 3 to 6 months. We usually wait during higher-risk periods: pregnancy, upcoming travel, allergy season or high stress.
• Don’t stop ICS altogether if you are aged 6 years or older. It raises the risk of future exacerbations.

Children under 12 follow slightly different algorithms (see below).

Inhaler technique — often the biggest improvement you can make

Up to 70–90% of patients use their inhalers incorrectly, which can deliver less than half the dose. No change of medicine makes up for poor technique.

General pointers (details vary by device):

• Breathe out gently first to empty your lungs.
• Seal your lips tightly around the mouthpiece.
• Metered-dose inhalers (pMDIs, “puffers”): press as you start to breathe in slowly and deeply, then hold your breath for about 10 seconds if you can.
• Dry powder inhalers (DPIs) such as Turbohaler or Accuhaler: breathe in fast and deep, faster than with a pMDI.
• Wait about 30 seconds between puffs if you take more than one.
• Rinse your mouth and gargle after any ICS-containing inhaler to reduce the risk of oral thrush and hoarseness.
• Use a spacer (e.g. Aerochamber) with a pMDI. It greatly improves delivery and is essential for children and anyone with poor coordination.

We watch you use your inhaler at every follow-up and correct any drift. Even long-standing patients pick up small errors over the years.

Your asthma action plan

Everyone with asthma should have a written asthma action plan (WAAP), a one-page guide with three levels.

1. Green zone (well controlled): your usual daily treatment. Symptoms are infrequent, with no night waking or activity limits. Peak flow, if measured, is usually ≥80% of your personal best.
2. Yellow zone (worsening): what to step up, when and for how long, typically more ICS or ICS-formoterol. Peak flow is 50–79% of your best, or symptoms are worsening (more reliever use, some night waking, activity limits).
3. Red zone (danger): what to do (often a short course of oral prednisolone) and when to come in or call 995. Peak flow is under 50%, or you are severely breathless whatever the reading.

We usually suggest a peak flow meter if you’ve had an exacerbation, find early symptoms hard to sense, or have moderate-to-severe asthma. Your zones are based on your personal best, set over 2 weeks of twice-daily readings while well, not a published “normal”.

If you don’t have a written plan tailored to you, ask for one at your next visit.

How controlled is your asthma? — the GINA 4-question check

This shows how well controlled your asthma really is. Over the past 4 weeks:

1. Have you had daytime asthma symptoms more than twice a week?
2. Have you had any night waking due to asthma?
3. Have you needed your reliever for symptoms more than twice a week (not counting pre-exercise doses)?
4. Has asthma limited your activity at work, school, exercise or daily life?

Scoring:

• 0 yes answers: well controlled. Carry on and review periodically.
• 1–2 yes: partly controlled. Your plan may need adjusting.
• 3–4 yes: uncontrolled. Please come in rather than pushing through.

We use this GINA check at every follow-up. Doing it yourself between visits can show when to come back sooner.

Triggers and what influences control — the BREATHE checklist

At each review, the ACE guideline’s BREATHE checklist looks beyond the inhaler:

• Beliefs, knowledge and attitudes, including common misconceptions about asthma or steroids
• Recent asthma treatment: what you actually use, and how often, versus what was prescribed
• Effects of asthma on quality of life, work, sleep, school and exercise
• Adherence: if a plan isn’t being followed, we would rather know why and adjust it
• Triggers: dust mites, pet dander, cockroaches, pollens, haze, tobacco smoke (including second-hand), workplace exposures, exercise, cold air, viral infections, certain medicines (aspirin/NSAIDs, non-selective beta-blockers)
• History of asthma, including previous severe attacks or ICU admissions (a strong predictor of future severe attacks)
• Existing comorbidities or medicines: allergic rhinitis, sinusitis, GORD, obesity, obstructive sleep apnoea, mental health conditions

Trigger measures worth the effort:

• For clear dust-mite allergy: dust-mite-proof mattress and pillow covers, hot-washed bedding, fewer soft furnishings in bedrooms
• No smoking, and avoid second-hand smoke
• In the haze season, keep your reliever to hand and cut outdoor exercise on bad AQI days
• Annual flu vaccination (see below)
• Treat allergic rhinitis: for many people, a well-controlled nose means well-controlled lower airways

When things worsen — exacerbations

Signs your asthma is leaving the green zone:

• Reliever use more than twice a week (beyond pre-exercise doses)
• Waking at night with cough or breathlessness, even once or twice
• Daytime symptoms most days
• Breathlessness with normal activities such as stairs or walking
• Peak flow falling from your personal best, if you monitor it

Act early. A flare treated early, by stepping up ICS-containing treatment and sometimes a short course of oral prednisolone under our guidance, is far more likely to settle than one ignored for a week. Come in sooner rather than later.

Come in urgently, call 995 or go to A&E if you have:

• Severe breathlessness: unable to speak in full sentences, or struggling to breathe at rest
• A reliever that isn’t working: needing it more often than every 4 hours without relief
• Rapidly worsening symptoms
• Blue lips or fingertips, or confusion
• A sense that something is seriously wrong

Severe attacks can worsen quickly. If it’s bad, don’t drive yourself: take a taxi, call a friend or call 995.

A short note on children with asthma

Most adult principles apply to children. For more, see Asthma in children — what parents need to know. Briefly:

• Under 6: usually daily low-dose ICS or a leukotriene receptor antagonist (montelukast/Singulair), with a SABA reliever. MART is not generally used at this age.
• Ages 6–11: ICS-formoterol MART is an option, but the algorithm differs slightly from adults.
• Spacers with a face mask are essential for young children using a pMDI.
• School asthma plans: give the school or childcare a copy of the action plan. Most schools can also hold a spare reliever.
• Montelukast (Singulair): Singapore’s Health Sciences Authority has an advisory on possible neuropsychiatric effects (mood change, agitation, occasionally suicidal thoughts). It is still useful for some children. We discuss the risks and ask caregivers to watch for mood or behaviour changes.

Childhood asthma often improves significantly through adolescence, more smoothly if it is well controlled early.

Comorbidities that affect asthma control

These conditions often travel with asthma and make it harder to control. Treating them usually helps breathing too:

• Allergic rhinitis (runny nose, post-nasal drip, itchy eyes): a nasal corticosteroid spray is often the most useful add-on when an adult’s asthma isn’t quite controlled
• Gastro-oesophageal reflux (GORD): reflux symptoms can worsen cough and night-time asthma, and treating them helps. Acid suppression without reflux symptoms doesn’t reliably help asthma, so we treat GORD only when clinically present.
• Obesity: losing weight often improves asthma meaningfully
• Obstructive sleep apnoea: common in middle-aged adults with asthma and worth screening for
• Smoking (including vaping): makes ICS less effective and worsens long-term outcomes
• Anxiety and depression: affect both symptoms and self-management, so worth asking about

Regular follow-up — and why it matters

People with well-controlled asthma often stop coming for review, but we recommend at least two visits a year, and more after a flare-up or treatment change:

• Guidance has changed, especially around ICS-formoterol. A plan from 5 years ago may no longer be the best option.
• Inhaler technique and adherence drift. A short check and a non-judgemental conversation catch this early.
• Other conditions develop. Nose, reflux, weight or mood changes can quietly worsen asthma.
• Severe attacks are more predictable than most people realise. We look for risk features (high SABA use, a recent exacerbation, too little preventer) and act on them.

The ACE guideline recommends review:

• Within 1–2 weeks after an exacerbation
• Within 1–3 months after starting or changing treatment
• Every 1–3 months if you are at higher risk of poor outcomes
• At least twice a year for everyone else

Vaccinations

People with asthma should be up to date with:

• Annual influenza (flu) vaccination, since respiratory viruses trigger many exacerbations
• Pneumococcal vaccination, to reduce the risk of serious respiratory infection
• COVID-19 boosters as recommended
• Tdap (tetanus/diphtheria/pertussis) in each pregnancy, ideally at 16–32 weeks

We check vaccinations at every visit. Many are subsidised under the National Adult Immunisation Schedule (NAIS) and the National Childhood Immunisation Schedule (NCIS).

The Singapore context — programmes that support you

• Healthier SG Chronic Tier (from February 2024): if you are enrolled with us and hold a CHAS, Pioneer Generation or Merdeka Generation card, common asthma medicines (ICS, ICS-LABA, SABA, spacers) cost about the same as at polyclinics.
• Community Health Assist Scheme (CHAS): means-tested subsidies for consultations and selected medicines at participating GP clinics, with extra benefits for Pioneer and Merdeka Generation cardholders. More at chas.sg.
• MediSave: usable for chronic disease consultations and selected medicines under the MediSave500/700 scheme, up to the annual withdrawal limit (currently $500, or $700 for complex chronic conditions). From January 2027 the limits rise to $700 / $1,000 and the scheme is renamed the MediSave Chronic and Preventive Care scheme.
• Primary Care Networks (PCN): KTMC is part of Class PCN, which supports nurse counselling, spirometry arrangements and chronic disease registry tracking.

Get in touch

Punggol — 658 Punggol East, #01-04, Singapore 820658 · Tel 6312 4589

Joo Chiat — 172 Joo Chiat Road, #01-01, Singapore 427443 · Tel 6920 1952

Email — admin@ktmc.sg

References

Guidelines and national programmes

• Agency for Care Effectiveness (ACE). Asthma — optimising long-term management with inhaled corticosteroid. ACE Clinical Guidance, Ministry of Health, Singapore. October 2020. ace-hta.gov.sg
• Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention — 2026 update. ginasthma.org
• British Thoracic Society / NICE / SIGN. Joint guideline for the diagnosis, monitoring and management of chronic asthma in adults, adolescents and children over 12 years. 2024. nice.org.uk
• Health Sciences Authority Singapore. Drug Safety Information No. 71 — advisory on montelukast and neuropsychiatric effects.
• Ministry of Health Singapore. National Adult Immunisation Schedule (NAIS). healthhub.sg
• Ministry of Health Singapore. Keeping healthcare affordable — MediSave500/700 limits rising to $700 / $1,000 and scheme renamed MediSave Chronic and Preventive Care from 1 January 2027. 5 March 2026. moh.gov.sg

SABA overuse and safety

• Nwaru BI, Ekström M, Hasvold P, Wiklund F, Telg G, Janson C. Overuse of short-acting β2-agonists in asthma is associated with increased risk of exacerbation and mortality: a nationwide cohort study of the global SABINA programme. Eur Respir J. 2020;55(4):1901872. ersjournals.com
• MHRA (UK). Short-acting beta-2 agonists (SABA): reminder of the risks from overuse in asthma. Drug Safety Update, 2024. gov.uk

This information is for general education only and is not a substitute for medical advice. Asthma management must be individualised to your symptom pattern, triggers, and response to treatment — please speak with our team about what’s right for you. v1.1 · October 2026 (v1.0 April 2026) · Review due April 2028.