The problem: asthma treated by guesswork

In everyday practice, many patients with a cough or a "chest problem" are given an inhaler after a short consultation, sometimes without a single breathing test. Some do have asthma. Others have a post-infectious cough, allergic rhinitis with post-nasal drip, acid reflux, COPD, vocal cord problems or even a heart condition. Treating all of these as asthma means some patients take inhalers they do not need, and others with true asthma stay under-treated because their severity was never measured.

That is why we follow a structured pathway, in line with international asthma guidelines, that we explain below.

Step 1: Confirm asthma before treating it

We do not start long-term inhalers on symptoms alone. Asthma is a diagnosis of variable airflow limitation, and it can be shown with tests:

• Detailed history: pattern of cough and wheeze, night and early-morning symptoms, triggers (dust, pollen, smoke, cold air, exercise, infections), family history of allergy and asthma, occupation and home environment.
• Spirometry with bronchodilator reversibility: measures how fast and how much air you can blow out, and whether it improves after a reliever inhaler.
• FeNO (fractional exhaled nitric oxide): a quick, painless breath test that shows allergic (eosinophilic) inflammation in the airways.
• Peak flow monitoring when needed, to show day-to-day variation.
• Examination and other tests to rule out look-alikes such as COPD, reflux cough, bronchiectasis or heart disease.

Step 2: Grade the disease with objective investigations

Once asthma is confirmed, "mild" and "severe" should not be guesses. We look at how severe the disease is, what type of inflammation is driving it, and what is making it worse:

We then combine these results with your symptoms, night-time waking, reliever use and past attacks to place you in a clear category (intermittent, mild, moderate or severe) and to check whether your asthma is currently controlled, partly controlled or uncontrolled. Where relevant, chest X-ray and other tests are added to look for complications or other causes.

Step 3: Check inhaler technique, dose and compliance

Most "failed" inhalers have not failed at all. Studies consistently show that a large number of patients use their device incorrectly, and a poorly used inhaler delivers only a fraction of the medicine to the lungs. At every visit we therefore check three things:

• Technique: we watch you use your device (pMDI, spacer, dry powder or other) and correct each step: shaking, breathing out, timing, breath-hold and mouth rinsing.
• Dose: we make sure the strength and frequency match your grade of asthma, and we step it up or down as your control changes, rather than continuing the same dose for years.
• Compliance: we ask honestly how often doses are missed and why: cost, fear of "steroid dependence", feeling better and stopping, or simple forgetfulness. Then we solve that problem.

Inhaled medicines act directly in the airways with far smaller doses than tablets or injections, so they are the safest, most effective way to control asthma when used correctly. The goal is to use them well, not to avoid them.

Step 4: A personalised management plan

• Controller and reliever plan matched to your severity and test results.
• Treating what surrounds asthma: allergic rhinitis, sinusitis, reflux, obesity, smoking exposure and poor sleep.
• Trigger control: practical steps for dust, pollen season, smoke and weather. See our detailed guide: Why Pollen Allergy Is So Severe in Islamabad and How to Prevent It.
• Written asthma action plan: what to do when symptoms worsen, and when to seek urgent care.
• Regular follow-up with repeat spirometry and FeNO to step treatment down when you are well controlled, or up if needed.
• Advanced options for severe asthma: when asthma remains uncontrolled despite correct inhaler use, we assess for allergic or eosinophilic patterns and discuss further options with the patient.

Why this approach makes a difference

• Right diagnosis: fewer people on unnecessary long-term treatment.
• Right grade: treatment is neither too weak nor too strong.
• Right technique: the medicine actually reaches the lungs.
• Right follow-up: control is measured, not assumed.

Two consultant pulmonologists reviewing the same patient's tests also means a second opinion is built into the process.

Who should visit IRC?

• Cough or wheeze lasting more than 2–3 weeks, or returning each season
• Night-time or early-morning breathlessness
• Already using inhalers but still having symptoms or attacks
• Repeated courses of steroids, nebulisation or emergency visits
• Uncertainty about whether you really have asthma