Asthma & Airway Disease
Bronchial Asthma: What Every Patient and Family in Pakistan Needs to Know
Millions of Pakistanis live with asthma without ever achieving proper control — because the condition is under-diagnosed, inhalers are used incorrectly, and triggers specific to our environment are rarely addressed. A pulmonologist explains the disease clearly, from causes to treatment to what to do during an attack.
Dr. Nabila Zaheer Pulmonologist & Respiratory Specialist
Published June 23, 2026
Read time 12 min
A young woman in her late twenties came to my clinic unable to finish a sentence without stopping to catch her breath. She had been told, more than once over the years, that she had a "weak chest" or recurring chest infections, and had been prescribed multiple courses of antibiotics that never really resolved anything. What she actually had was asthma — undiagnosed, untreated, and by the time she reached me, significantly affecting her work and sleep.
This is not an unusual story. Asthma is one of the most common chronic conditions I see in clinic, and it is also one of the most frequently mismanaged — not because it is difficult to treat, but because the diagnosis is often delayed, the correct inhaler technique is almost never taught, and the environmental triggers specific to life in Pakistan are rarely discussed. This article is my attempt to address all of that plainly.
Bronchial asthma is a chronic inflammatory disease of the airways that is both very common and very controllable when managed properly. The majority of my asthma patients, once on the right treatment plan, live entirely normal, active lives. The condition itself is not the obstacle — the gap between what is possible and what most patients actually experience is.
262 million people affected by asthma globally, making it one of the most common chronic diseases worldwide
~450,000 deaths per year — the majority of which are preventable with appropriate treatment
70% of asthma patients use their inhalers incorrectly, significantly reducing how well medication reaches the lungs
What Is Bronchial Asthma?
Bronchial asthma is a chronic inflammatory condition affecting the airways — the tubes that carry air in and out of the lungs. In a person with asthma, these airways are persistently inflamed and hypersensitive. When exposed to certain triggers, three things happen simultaneously: the muscles surrounding the airways tighten (bronchoconstriction), the airway lining swells (inflammation), and excess mucus is produced. Together, these narrow the airway and make breathing significantly harder.
The crucial thing to understand about asthma is that it is not simply a series of isolated attacks with normal airways in between. Even when you feel well, the underlying airway inflammation is still present. This is why controller medication — taken daily, even on symptom-free days — is the foundation of good asthma management, and why stopping treatment as soon as you feel better is one of the most common mistakes I see.
Asthma is also a condition of considerable variability. Some people have mild, occasional symptoms triggered by a specific factor such as exercise or cold air. Others have daily symptoms that significantly limit their activities. Most people sit somewhere in between, and the same person's asthma can change over months and years — which is why regular review with a pulmonologist matters even when you feel you are coping.
Causes and Risk Factors
Asthma develops through a combination of genetic susceptibility and environmental exposure. No single gene or single exposure causes asthma on its own; it is the interaction between a predisposed airway and the right environmental conditions that produces the disease.
Genetic Predisposition
Having a parent or sibling with asthma increases your own risk by three to six times. A personal or family history of other allergic conditions — eczema, allergic rhinitis (hay fever), or food allergies — also substantially increases risk. This grouping of allergic conditions in individuals and families is called atopy, and atopic individuals are the largest group among asthma patients.
Environmental and Early-Life Factors
- Exposure to tobacco smoke, both during pregnancy and in the first years of childhood
- Frequent respiratory infections in early childhood, particularly viral bronchiolitis
- Sustained exposure to indoor and outdoor air pollution
- Occupational exposures to dusts, chemical fumes, flour, or latex
- Obesity — excess body weight promotes systemic inflammation and increases mechanical pressure on the lungs
- Low birth weight and prematurity, which affect lung development
Where Asthma Comes From in Pakistan: Triggers Specific to Our Environment
Triggers are not the same as causes. They do not give you asthma — they provoke episodes in airways that are already sensitised. In Pakistan, several triggers are particularly significant and are worth discussing specifically, because generic asthma education rarely addresses them.
🌫️ Air pollution and smog season
Lahore, Karachi, Peshawar, and Rawalpindi regularly rank among the most polluted cities in the world. From October through January, smog season — driven largely by crop-residue burning, vehicle emissions, and brick kiln output — produces sustained periods of hazardous air quality that trigger asthma attacks and worsen control in patients across Punjab and beyond.
🌾 Crop burning (October–November)
Stubble burning after the rice harvest in central Punjab releases enormous quantities of fine particulate matter over weeks. Hospitals across the region see a consistent spike in respiratory admissions during this period. Patients with asthma should have a reviewed action plan in place before this season each year.
🌿 Dust mites and indoor allergens
Pakistan's climate — warm and humid in many parts — is ideal for house dust mite proliferation. Dust mite sensitisation is one of the most common allergic triggers I identify in asthma patients across age groups. Pet dander, cockroach allergens, and indoor mold are also common contributors.
🏜️ Dust storms
Seasonal dust storms, particularly in Sindh, southern Punjab, and Balochistan, can trigger sudden severe attacks. Fine particulate matter from these storms reaches deep into the airways and is a significant hazard for asthma patients without a protective plan.
🕯️ Indoor combustion
Burning of wood, dung, or biomass for cooking and heating — still common in rural and peri-urban areas — produces indoor smoke that is a potent airway irritant. Incense burning and heavy use of strong chemical cleaning agents are urban equivalents worth recognising.
🏃 Exercise in cold or polluted air
Exercise-induced bronchoconstriction is common and manageable, but exercising during high-pollution days or in cold, dry air significantly increases the likelihood of a post-exercise episode. This does not mean patients should avoid exercise — it means it should be done at the right time and place.
Recognising Asthma: Symptoms That Should Prompt Evaluation
The four classical symptoms of asthma are wheezing (a high-pitched whistling sound on breathing out), breathlessness, chest tightness, and a persistent cough — often worse at night or early in the morning. Importantly, you do not need all four to have asthma. Some patients have only a chronic cough with no wheeze at all, a pattern called cough-variant asthma that is frequently misdiagnosed as a respiratory infection or reflux.
Symptoms that should prompt a formal respiratory evaluation include:
- Breathlessness that is disproportionate to the level of activity, particularly if it has worsened gradually over weeks or months
- A dry cough lasting more than three weeks without a clear infectious cause
- Recurrent chest tightness or wheeze, especially if it responds to a salbutamol inhaler or worsens in specific environments
- Nighttime cough or breathlessness that wakes you from sleep — nocturnal symptoms are a particularly reliable indicator of poorly controlled asthma
- Symptoms that follow a pattern — worsening with exercise, in cold air, during smog season, in specific buildings, or after exposure to animals
🚨 Signs of a Severe Asthma Attack — Seek Emergency Care Immediately
- Extreme difficulty breathing — unable to complete a full sentence between breaths
- Bluish or grey colour around the lips or fingernails (cyanosis)
- Reliever inhaler providing no relief, or relief lasting only a few minutes
- A silent chest — no wheeze despite obvious severe breathing difficulty (this means airflow is critically low)
- Confusion, drowsiness, or altered consciousness
Call emergency services immediately. In Punjab: 1122. Nationwide Rescue: 115.
How Asthma Is Classified
Doctors use a severity classification to guide initial treatment decisions. The classification most commonly used in clinical practice is based on symptom frequency, nighttime symptoms, and lung function:
Intermittent — Daytime symptoms two days per week or fewer, nighttime symptoms two nights per month or fewer, lung function at or above 80% of predicted.
Mild Persistent — Daytime symptoms more than two days per week, nighttime symptoms three to four nights per month, lung function at or above 80% of predicted.
Moderate Persistent — Daily daytime symptoms, nighttime symptoms more than one night per week, lung function between 60% and 79% of predicted.
Severe Persistent — Continuous daytime symptoms, nighttime symptoms most nights, lung function below 60% of predicted.
It is important to understand that severity classification guides the starting point of treatment — but what matters most in ongoing management is the concept of control: how well the current treatment is suppressing symptoms. A patient with severe asthma who is well-controlled on appropriate treatment is in a far better position than a patient with moderate asthma who is poorly controlled because they are on inadequate treatment or using their inhaler incorrectly.
Diagnosing Asthma
There is no single test that diagnoses asthma on its own. The diagnosis is built from a combination of clinical history, physical examination, and objective lung function measurements.
Spirometry
This is the most important diagnostic test. It measures how much air you can breathe out and how fast, providing the FEV₁/FVC ratio that distinguishes obstructive airway disease from other conditions. In asthma, this ratio is reduced, and — crucially — it improves significantly after a bronchodilator is inhaled (at least 12% improvement in FEV₁), confirming the reversibility that is characteristic of asthma.
Peak Expiratory Flow Monitoring
A peak flow meter is a simple, inexpensive handheld device that measures the speed of exhalation. Recording peak flow readings twice daily over two to four weeks reveals the variability that is characteristic of asthma — readings are typically lower in the early morning and higher during the afternoon. Variability of more than 20% across the day supports the diagnosis. Peak flow monitoring is also invaluable for self-management: a falling peak flow can warn of deteriorating control before symptoms become severe.
Bronchodilator Reversibility Testing
If baseline spirometry shows airflow obstruction, a short-acting bronchodilator (salbutamol) is administered and spirometry is repeated fifteen minutes later. Significant improvement confirms reversible airflow obstruction — the hallmark of asthma.
Allergy Testing
Skin prick testing or blood allergen-specific IgE measurements identify sensitisation to specific triggers — dust mites, pollen, pet dander — which is relevant both to understanding the patient's disease and to considering allergen-specific immunotherapy in selected cases.
Chest X-ray
Usually normal in asthma, but essential for excluding other diagnoses — tuberculosis, pneumonia, heart failure, or lung masses — particularly in adult-onset presentations in Pakistan where TB remains common.
The diagnosis of asthma is one of the most straightforward diagnoses I make — when I take a careful history. The pattern of symptoms, the triggers, the timing, the family history of atopy, the response to a salbutamol inhaler: when these elements are present, the clinical picture is usually clear before the spirometry is even done. What concerns me is how often this history is never properly taken, and patients are instead labelled with recurrent infections and prescribed antibiotics repeatedly for years.
— Dr. Nabila Zaheer, Pulmonologist
Treatment: What Good Asthma Management Actually Looks Like
Asthma has no cure, but it is one of the most controllable chronic conditions in medicine. The goal of treatment is complete symptom control — no daytime or nighttime symptoms, no limitation on activity, no need for reliever medication more than twice a week, and lung function maintained at or near normal.
Reliever Medications
Short-acting beta-agonists, most commonly salbutamol (Ventolin), are the first-line treatment for acute symptoms. They work within minutes by relaxing the muscles around the airway and should always be available to the patient. However, if you are using your reliever inhaler more than twice a week for symptoms, that is a clear signal that your underlying inflammation is not adequately controlled and your treatment plan needs review — it is not a reason to simply carry more salbutamol.
Controller Medications
Inhaled corticosteroids (ICS) are the cornerstone of asthma control. Budesonide, fluticasone, and beclomethasone are the most commonly used. They reduce airway inflammation at the source, taken daily even on symptom-free days, and are the single most effective intervention for preventing attacks. They are not the same as anabolic steroids; inhaled at prescribed doses, they act locally in the airways with minimal systemic absorption and are safe for long-term use.
For patients whose asthma is not controlled by ICS alone, a long-acting beta-agonist (LABA) such as formoterol or salmeterol is added — always in combination with an ICS, never used alone. Montelukast (a leukotriene receptor antagonist) is a useful oral add-on, particularly for patients with allergic asthma or exercise-triggered symptoms. For the most severe, refractory cases, biologic therapies targeting specific inflammatory pathways — such as omalizumab or mepolizumab — are now available and can be transformative for appropriately selected patients.
Correct Inhaler Technique: The Most Under-Addressed Issue in Asthma Care
Studies consistently show that up to seventy percent of asthma patients use their inhalers incorrectly. Poor technique means a significant portion of the medication deposits in the mouth or throat rather than reaching the lungs — and the patient experiences poor control despite being on the right medication at the right dose. This is one of the most impactful things I address in every asthma review appointment.
For a pressurised metered-dose inhaler (pMDI), correct technique:
- Shake the inhaler well for five seconds before use
- Breathe out fully away from the inhaler, emptying the lungs
- Place the mouthpiece in the mouth and seal the lips tightly around it
- Begin breathing in slowly and steadily, then press the canister once at the start of the breath
- Continue inhaling slowly and deeply for four to five seconds
- Hold the breath for ten seconds to allow the medication to settle in the airways
- Wait sixty seconds before a second puff if one is prescribed
✅ Use a Spacer Device — It Makes a Measurable Difference
A spacer (valved holding chamber) attached to your pMDI inhaler removes the need to perfectly coordinate pressing and inhaling, and substantially increases the proportion of medication that reaches the lungs rather than depositing in the mouth. It is particularly important for children and elderly patients, and for anyone taking inhaled corticosteroids — using a spacer significantly reduces the risk of oral thrush from ICS. I recommend spacers routinely for any patient on a pMDI. Ask your doctor or pharmacist at your next appointment.
Non-Medication Management
- Written Asthma Action Plan: A personalised document from your pulmonologist that tells you exactly what to do when your symptoms are well-controlled, worsening, or severe. Every asthma patient should have one, understand it, and keep it accessible.
- Trigger identification and avoidance: Dust-mite proof mattress and pillow covers, keeping bedroom windows closed on high-pollution days, avoiding strong chemical sprays, and not smoking or allowing smoking near the patient.
- Annual influenza vaccination: Flu is a major precipitant of severe asthma attacks. Vaccination is recommended for all asthma patients.
- Weight management: Even a five to ten percent reduction in body weight in overweight patients produces a clinically meaningful improvement in asthma control.
- Breathing exercises: Specific techniques, particularly the Buteyko method, have evidence supporting a reduction in reliever use when practised consistently alongside medication.
- Regular review: Asthma control should be formally assessed every one to three months. The question is not just whether you are having attacks — it is whether you are achieving the level of control that modern treatment can provide.
Managing an Acute Asthma Attack at Home
Every asthma patient should know what to do during an attack before one happens. The following is the standard four-puff protocol that should be part of every patient's written action plan:
⚠️ During an Asthma Attack — Step by Step
- Stay as calm as possible and sit upright, leaning slightly forward. Do not lie down.
- Take four puffs of salbutamol via spacer (one puff at a time, four normal breaths per puff) — or two to four puffs directly from the inhaler if no spacer is available.
- Wait four minutes and reassess. If no improvement, repeat four puffs.
- If there is still no improvement after the second round — call for emergency help immediately. Do not wait further.
- Continue giving four puffs every four minutes while waiting for emergency assistance to arrive.
Frequently Asked Questions
Can asthma be cured permanently?
There is currently no permanent cure for asthma. Some children with mild asthma appear to have fewer or no symptoms in adulthood — sometimes described as outgrowing asthma — though the underlying airway sensitivity often persists, and symptoms can return later in life. With appropriate treatment, the large majority of patients can achieve complete symptom control and live without limitations. The aim of treatment is not cure but sustained, high-quality control.
Are inhaled steroids safe for long-term use?
Yes. Inhaled corticosteroids are safe for long-term use at prescribed doses because they act locally within the airways and very little is absorbed systemically. They are substantially safer than oral steroids, which carry significant systemic effects. The risks of untreated or poorly controlled asthma — attacks, hospitalisation, irreversible airway remodelling over time — far outweigh any small risks from inhaled corticosteroids taken appropriately. Rinsing your mouth with water after each use is recommended to prevent local oral thrush.
Can I exercise with asthma?
Yes, and regular aerobic exercise actively improves asthma control over time by strengthening respiratory muscles and reducing systemic inflammation. If exercise triggers your symptoms, two puffs of salbutamol fifteen minutes before activity usually provides good protection. Swimming is particularly well-tolerated because the warm, humid air at pool level is less likely to provoke bronchoconstriction. Avoid exercising outdoors during high-pollution days or in very cold, dry air. Exercise restriction is not appropriate asthma management — exercise is part of good asthma management.
What is a peak flow meter and do I need one?
A peak flow meter is a small, inexpensive handheld device that measures how fast you can exhale. Regular twice-daily readings provide an objective measure of your airway function that often detects deteriorating control before symptoms worsen enough to be obvious — giving you time to step up treatment early rather than waiting for a severe attack. I recommend home peak flow monitoring for all my moderate and severe asthma patients, and particularly during smog season and other high-risk periods. Your pulmonologist can set you a personal best value and build action thresholds around it.
My child has been diagnosed with asthma. What should I tell the school?
Inform the school nurse and the class teacher directly. Provide a written asthma action plan signed by your doctor, and ensure a salbutamol inhaler with spacer is kept at school in an accessible location. Teachers should be able to recognise the signs of an asthma attack and know when to call for help. During smog season and examination periods — both of which increase risk — stay in close contact. Advocate clearly and specifically: do not assume the school has systems in place unless you have personally confirmed them.
I feel fine between attacks — do I still need to take my daily inhaler?
Yes. This is perhaps the most common reason for poor asthma control I encounter. Controller inhalers — particularly inhaled corticosteroids — work by reducing underlying airway inflammation, which is present even when you feel well. Stopping them when you feel better removes the protection that is preventing symptoms. Asthma control is not the same as the absence of current symptoms; it is the suppression of the chronic inflammatory process that causes symptoms. Taking your controller inhaler daily as prescribed, even on good days, is the single most important thing you can do for long-term control.
Recommended Products for Asthma Management
Based on my experience as a pulmonologist, these are the products I most commonly recommend to asthma patients to support better monitoring and medication delivery at home:
- Peak Flow Meter — An essential home monitoring tool for asthma patients; regular readings detect worsening control before symptoms become severe, allowing timely action rather than waiting for an attack.
👉 Check on Amazon Pakistan / Amazon.in - Inhaler Spacer Device (Valved Holding Chamber) — Dramatically improves how much medication reaches the lungs from a pMDI inhaler, reduces side effects from inhaled corticosteroids, and is particularly important for children, elderly patients, and anyone who has difficulty coordinating pressing and inhaling simultaneously.
👉 Check on Amazon Pakistan / Amazon.in - HEPA Air Purifier — Removes dust mites, pollen, pet dander, and fine airborne particulate matter from indoor air — the most common asthma triggers in Pakistani homes — making the bedroom and living space meaningfully safer to breathe in, particularly during smog season.
👉 Check on Amazon Pakistan / Amazon.in
Affiliate Disclosure: As an Amazon Associate, I earn from qualifying purchases. I only recommend products I believe are helpful for my patients.
Breathing Difficulties Should Not Be Accepted as Normal.
If you have been told you have a "weak chest," are using your reliever inhaler more than twice a week, or are experiencing nighttime symptoms or exercise limitation — your asthma is not adequately controlled, and it can be. Book a consultation with Dr. Nabila Zaheer at PulmoCare today.
Medical Disclaimer: This article is written for general informational and educational purposes only. It does not constitute medical advice and should not replace a consultation with a qualified healthcare professional. If you have symptoms of asthma or concerns about your respiratory health, please seek evaluation from a licensed physician. Dr. Nabila Zaheer is a board-certified pulmonologist at PulmoCare, Rawalpindi — click here to book a consultation.