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VOLUME 10 , ISSUE 2 ( May-August, 2021 ) > List of Articles


Challenges with Present Symptom Control and Risk Reduction of Future Exacerbations in Asthma: Indian Patients’ Perspectives

Raghupathi Narasimhan, Lancelot Pinto, Susmita Roy Choudhary, Nila Velayudhan

Keywords : Global Initiative for Asthma, maintenance, single inhaler

Citation Information : Narasimhan R, Pinto L, Choudhary SR, Velayudhan N. Challenges with Present Symptom Control and Risk Reduction of Future Exacerbations in Asthma: Indian Patients’ Perspectives. Indian J Respir Care 2021; 10 (2):190-195.

DOI: 10.4103/ijrc.ijrc_59_19

License: CC BY-NC-SA 4.0

Published Online: 06-12-2022

Copyright Statement:  Copyright © 2021; Indian Journal of Respiratory Care.


Asthma poses a serious burden and remains poorly understood and unrecognized, in lower- and middle-income countries such as India where healthcare resources are already constrained. Several misconceptions exist among Indian patients regarding asthma, including the nature of the disease. Poor adherence to maintenance treatment leads to inadequate control of underlying inflammation which, in turn, increases the chances of subsequent exacerbations. Effective management of asthma should aim to control symptoms, decrease risk of exacerbations, and minimize fixed airflow limitation and side effects. Patient education and counseling also play a key role. A control-based management of asthma is recommended with the adjustment of medications via a stepwise approach. A single inhaler for both maintenance and reliever therapy offers an approach that can provide rapid relief, simplify asthma therapy, and prevent asthma exacerbations, while decreasing the total corticosteroid dose taken over time. For this review, a literature search was conducted using PubMed and other library searches to collate data on the Indian patients’ perspectives on the level of asthma control and the associated risk of asthma exacerbations. We discuss the perceptions among Indian asthma patients regarding the disease, the gaps in asthma management, the key aspects of Global Initiative for Asthma Guidelines, and the role of single inhaler for both maintenance and reliever therapy in the management of asthma.

  1. The Global Asthma Report 2014. Auckland, New Zealand: Global Asthma Network; 2014. Available from: [Last accessed on 2017 Oct 26].
  2. World Health Organization Media Centre (Bronchial Asthma). World Health Organization Web Site; 2016. Available from: [Last accessed on 2016 Jul 20].
  3. To T, Stanojevic S, Moores G, Gershon AS, Bateman ED, Cruz AA, et al. Global asthma prevalence in adults: Findings from the cross-sectional world health survey. BMC Public Health 2012;12:204.
  4. Jindal SK, Aggarwal AN, Gupta D, Agarwal R, Kumar R, Kaur T, et al. Indian study on epidemiology of asthma, respiratory symptoms and chronic bronchitis in adults (INSEARCH). Int J Tuberc Lung Dis 2012;16:1270-7.
  5. Parasuramalu BG, Huliraj N, Rudraprasad BM, Prashanth Kumar SP, Gangaboraiah., Ramesh Masthi NR. Prevalence of bronchial asthma and its association with smoking habits among adult population in rural area. Indian J Public Health 2010;54:165-8.
  6. Nitin J, Palagani R, Shradha NH, Vaibhav J, Kowshik K, Manoharan R, et al. Prevalence, severity and risk factors of allergic disorders among people in South India. Afr Health Sci 2016;16:201-9.
  7. Aggarwal AN, Chaudhry K, Chhabra SK, D'Souza GA, Gupta D, Jindal SK, et al. Prevalence and risk factors for bronchial asthma in Indian adults: A multicentre study. Indian J Chest Dis Allied Sci 2006;48:13-22.
  8. GBD 2015 Chronic Respiratory Disease Collaborators. Global, regional, and national deaths, prevalence, disability-adjusted life years, and years lived with disability for chronic obstructive pulmonary disease and asthma, 1990-2015: A systematic analysis for the global burden of disease study 2015. Lancet Respir Med 2017;5:691-706.
  9. Salvi SS, Apte KK, Dhar R, Shetty P, Faruqi RA, Thompson PJ, et al. Asthma insights and management in India: Lessons learnt from the Asia Pacific-Asthma Insights and Management (AP-AIM) study. J Assoc Physicians India 2015;63:36-43.
  10. Thompson PJ, Salvi S, Lin J, Cho YJ, Eng P, Abdul Manap R, et al. Insights, attitudes and perceptions about asthma and its treatment: Findings from a multinational survey of patients from 8 Asia-Pacific countries and Hong Kong. Respirology 2013;18:957-67.
  11. Kotwani A, Chhabra SK, Tayal V, Vijayan VK. Quality of asthma management in an urban community in Delhi, India. Indian J Med Res 2012;135:184-92.
  12. Shivbalan S, Balasubramanian S, Anandnathan K. What do parents of asthmatic children know about asthma?: An Indian perspective. Indian J Chest Dis Allied Sci 2005;47:81-7.
  13. Bhattacharyya P, Paul R, Nag S, Bardhan S, Saha I, Ghosh M, et al. Treatment of asthma: Identification of the practice behavior and the deviation from the guideline recommendations. Lung India 2010;27:141-4.
  14. Sodhi R, Prasad R, Kushwaha RA, Kant S, Verma SK, Garg R, et al. A study to know the knowledge attitude and practices of patients of bronchial asthma. Int J Med Public Health 2013;3:159-62.
  15. Pandey A, Tripathi P, Pandey RD. Prescription pattern in asthma therapy at Gorakhpur hospitals. Lung India 2010;27:8-10.
  16. Barthwal MS, Deoskar RB, Rajan KE. Status of inhalation therapy in bronchial asthma in adults above twelve years of age in armed forces. J Assoc Physicians India 2005;53:681-4.
  17. Reddel HK, Bateman ED, Becker A, Boulet LP, Cruz AA, Drazen JM, et al. A summary of the new GINA strategy: A roadmap to asthma control. Eur Respir J 2015;46:622-39.
  18. Barthwal MS, Katoch CD, Marwah V. Impact of optimal asthma education programme on asthma morbidity, inhalation technique and asthma knowledge. J Assoc Physicians India 2009;57:574-6, 579.
  19. Jolly GP, Mohan A, Guleria R, Poulose R, George J. Evaluation of metered dose inhaler use technique and response to educational training. Indian J Chest Dis Allied Sci 2015;57:17-20.
  20. Kotwani A, Chhabra SK. Effect of patient education and standard treatment guidelines on asthma control: An intervention trial. WHO South East Asia J Public Health 2012;1:42-51.
  21. Ranaut V, Kaur S, Kaur S, Singh M. Compliance and myths regarding use of metered dose inhaler amongst caregivers of children suffering with asthma. Nurs Midwifery Res J 2014;10: 1-7.
  22. Gupta PP, Gupta KB. Awareness about the disease in asthma patients receiving treatment from physicians at different levels. Indian J Chest Dis Allied Sci 2001;43:91-5.
  23. Terzano C. Metered dose inhalers and spacer devices. Eur Rev Med Pharmacol Sci 1999;3:159-69.
  24. Aït-Khaled N, Enarson DA, Bencharif N, Boulahdib F, Camara LM, Dagli E, et al. Implementation of asthma guidelines in health centres of several developing countries. Int J Tuberc Lung Dis 2006;10:104-9.
  25. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention (2016 update). Available from: [Last accessed on 2017 Nov 02].
  26. Shahid S, Bhinder G, Dhanjal J. Knowledge, attitudes and practices (KAP) of primary care physicians of Central Mumbai Suburbs about childhood asthma. Internet J Asthma Allergy Immunol 2006;6:2.
  27. Behera D, Sehgal IS. Bronchial asthma – Issues for the developing world. Indian J Med Res 2015;141:380-2.
  28. Bateman ED, Buhl R, O'Byrne PM, Humbert M, Reddel HK, Sears MR, et al. Development and validation of a novel risk score for asthma exacerbations: The risk score for exacerbations. J Allergy Clin Immunol 2015;135:1457-64.e4.
  29. Kuna P, Kuprys-Lipinska I. Budesonide/formoterol for maintenance and reliever therapy: New quality in asthma management. Therapy 2008;5:495-512.
  30. Agarwal R, Khan A, Aggarwal AN, Gupta D. Is the SMART approach better than other treatment approaches for prevention of asthma exacerbations? A meta-analysis. Monaldi Arch Chest Dis 2009;71:161-9.
  31. Rabe KF, Pizzichini E, Ställberg B, Romero S, Balanzat AM, Atienza T, et al. Budesonide/formoterol in a single inhaler for maintenance and relief in mild-to-moderate asthma: A randomized, double-blind trial. Chest 2006;129:246-56.
  32. Sovani MP, Whale CI, Oborne J, Cooper S, Mortimer K, Ekström T, et al. Poor adherence with inhaled corticosteroids for asthma: Can using a single inhaler containing budesonide and formoterol help? Br J Gen Pract 2008;58:37-43.
  33. Balter M, Ernst P, Watson W, Kim H, Cicutto L, Beauchesne MF, et al. Asthma worsenings: Approaches to prevention and management from the Asthma Worsenings Working Group. Can Respir J 2008;15 Suppl B: 1B-19B.
  34. Aubier M, Buhl R, Ekström T, Ostinelli J, van Schayck CP, Selroos O, et al. Comparison of two twice-daily doses of budesonide/formoterol maintenance and reliever therapy. Eur Respir J 2010;36:524-30.
  35. Selroos O. A smarter way to manage asthma with a combination of a long-acting beta (2)-agonist and inhaled corticosteroid. Ther Clin Risk Manag 2007;3:349-59.
  36. Ställberg B, Ekström T, Neij F, Olsson P, Skoogh BE, Wennergren G, et al. A real-life cost-effectiveness evaluation of budesonide/formoterol maintenance and reliever therapy in asthma. Respir Med 2008;102:1360-70.
  37. Demoly P, Louis R, Søes-Petersen U, Naya I, Carlsheimer A, Worth H, et al. Budesonide/formoterol maintenance and reliever therapy versus conventional best practice. Respir Med 2009;103:1623-32.
  38. Sears MR, Boulet LP, Laviolette M, Fitzgerald JM, Bai TR, Kaplan A, et al. Budesonide/formoterol maintenance and reliever therapy: Impact on airway inflammation in asthma. Eur Respir J 2008;31:982-9.
  39. Riemersma RA, Postma D, van der Molen T. Budesonide/formoterol maintenance and reliever therapy in primary care asthma management: Effects on bronchial hyperresponsiveness and asthma control. Prim Care Respir J 2012;21:50-6.
  40. Louis R, Joos G, Michils A, Vandenhoven G. A comparison of budesonide/formoterol maintenance and reliever therapy vs. conventional best practice in asthma management. Int J Clin Pract 2009;63:1479-88.
  41. Zhong N, Lin J, Mehta P, Ngamjanyaporn P, Wu TC, Yunus F. Real-life effectiveness of budesonide/formoterol maintenance and reliever therapy in asthma patients across Asia: SMARTASIA study. BMC Pulm Med 2013;13:22.
  42. Barve KS, Joshi J, Karkhanis V. Use of beclomethasone/budesonide and formoterol adjustable dose as single maintenance and rescue therapy in the management of bronchial asthma. Indian J Allergy Asthma Immunol 2014;28:27-34.
  43. Gupta MC, Jindal P, Chaudhry D. Comparative study evaluating the effects of salmeterol/fluticasone and formoterol/budesonide combinations on lung functions and sleep quality in adults with moderate persistent asthma. J Pharma Res Clin Pract 2013;3:1-9.
  44. BTS/SIGN. British Guideline on the Management of Asthma. National Clinical Guideline. 2014. Available from: [Last accessed on 2017 Nov 02].
  45. Agarwal R, Dhooria S, Aggarwal AN, Maturu VN, Sehgal IS, Muthu V, et al. Guidelines for diagnosis and management of bronchial asthma: Joint ICS/NCCP (I) recommendations. Lung India 2015;32:S3-42.
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