Discover the facts about severe asthma, its symptoms and how it differs from other types of asthma and the treatment options available.

What is severe asthma?

Severe asthma is a type of asthma that does not respond well to standard asthma treatments. [1] The symptoms by definition, are more intense than regular asthmatic symptoms and can last for prolonged periods. Sufferers of severe asthma often find their symptoms persistent and difficult to control.

Having severe asthma can have a major impact on daily life, affecting everyday habits, work and social life.It can affect both children and adults, and can develop at any age. However, it’s a lot less common than a standard asthma diagnosis, affecting less than 10% of people with asthma. [1,2,3]

Although it can be difficult to cope with, and it can take time to find the right treatment combination, it can be effectively managed. It’s important that you look after yourself carefully by taking your medication exactly as prescribed, having regular asthma reviews, understanding your asthma triggers and communicating with your healthcare team, so they know when and how to adjust your medication regime.

More About Severe Asthma

What’s the difference between severe asthma and chronic asthma?

All types of asthma, no matter whether it is mild, moderate or severe, are chronic, long term conditions. Severe chronic asthma is categorized by the fact that it does not respond well to typical asthma treatments and medications.

What is severe bronchial asthma?

Severe bronchial asthma is another term for severe asthma. Both terms refer to the chronic inflammatory disease of the airways, typically characterized by bronchial hyperreactivity; this means the airways narrow more frequently than with typical asthma when the person is exposed to certain triggers. [4]

Black woman with inhaler
Cropped shot of an attractive young woman using a pump during an asthma attack in her living room

Symptoms of severe asthma

The symptoms include:

  • Coughing
  • Wheezing
  • Difficulty breathing
  • Shortness of breath
  • Chest tightness
  • Chest pain
  • Asthma attacks.

The symptoms can be unpredictable and occur during the day and night. They can affect people’s everyday lives and the ability to carry out normal tasks. If severe asthma symptoms aren’t controlled effectively, they can limit your ability to do daily tasks.

What are symptoms of a severe asthma attack?

If you suddenly experience a severe asthma attack, then you may experience one or more of the following symptoms:

  • Feeling that you need to stand up or sit in order to try and breathe more easily
  • Feeling confused or agitated
  • Being unable to speak in full sentences
  • Feeling very short of breath and unable to inhale or exhale fully
  • Rapid breathing
  • Symptoms that don’t get better after using a reliever inhaler.
  • A bluish tint to your lips, face or fingernails

With a very severe asthma attack, you might not cough or wheeze, like during a usual asthma attack. [5] This is because your airways may be so affected that you can’t get enough air in or out of your lungs to cause wheezing sounds or make you cough. This is a medical emergency and you should go to a hospital immediately.

Compared to mild asthma attacks that may only last a few minutes, severe asthma attacks can last from hours to days and may be life-threatening without medical attention.

How can my health team identify how severe my asthma is?

The asthma team will examine you and may perform some simple or more involved tests to determine how severe your asthma is. They will look at your symptoms,lung function, medications, and the number, frequency, and severity of your asthma attacks. [6]

What is airway remodeling?

One potential long-term effect of severe asthma, and particularly poorly controlled severe asthma, is a condition called airway remodeling. [7]

If you’ve had frequent bad asthma attacks or lots of asthma symptoms that you’ve been unable to control, your airways will get thicker, more inflamed, and scarred over time. This means the airway becomes narrower – making it harder to breathe, which makes your symptoms worse.

This is one of the reasons why it’s important to manage your asthma effectively, no matter how difficult it can seem with severe asthma. With good management, you can reduce the risk of airway remodeling.

Treatment and Lifestyle Changes

What is the treatment for severe asthma?

There is no single treatment or medication solution. Everyone is affected differently, and what works well for one person may have no effect on another. The same medications may be prescribed for someone who has a milder asthma, but at a much higher dose for someone with severe asthma. Treatment of severe asthma focuses on trying to control the symptoms. [8] You’ll be prescribed medication and treatment to manage the inflammation in your airways and prevent lung damage. You’ll also be advised to reduce the risk of coming into contact with asthma triggers as much as possible, as this will reduce your risk of having a severe asthma attack.

As a starting point, it can be helpful to be aware of the following medications:

  • A reliever inhaler – used to provide relief when you need it and should be carried with you at all times.
  • A preventer inhaler – contains corticosteroids that help to reduce swelling and inflammation in the airways. This needs to be taken every day, as prescribed by your doctor.
  • SMART therapy – a reliever-preventer combination option for those 4 years of age and older who have moderate to severe asthma. You may hear this referred to as MART or SMART therapy, which stands for Single Maintenance and
  • Reliever Therapy. You can read more about SMART therapy below.

If you’re diagnosed with severe asthma, you should speak to your doctor about a referral to a specialist clinic. Some primary care offices have dedicated asthma nurses that can offer specialist support.

What are some additional medications for severe asthma?

In addition to inhalers, people with severe asthma may be prescribed other treatments. You may need to try several options before your healthcare provider finds the right choice for your needs.


In addition to inhalers, treatment options [8] include:

  • Long-acting bronchodilators (LBAs) – these can be added to a preventer inhaler and help keep the airways open for at least 12 hours.
  • Leukotriene receptor antagonists (LTRAs) – a non-steroid tablet that helps to calm inflamed airways, block the effects of leukotrienes (inflammatory molecules), and help with allergies.
  • Long-acting muscarinic receptor antagonists (LAMAs) – a form of long-acting bronchodilator that can work for 12-24 hours.
  • Long-acting beta-agonists (LABAs) – another form of long-acting bronchodilator that is used to relax the muscles in the airways.
  • Slow-release theophylline [9] – a non-steroid tablet that helps to relax the smooth muscles in the airways, enabling air to more easily flow through.
  • Short-acting beta 2-agonists – a form of quick relief medication that can be used when asthma symptoms occur.
  • Daily steroids – these are prescribed in tablet or liquid form and are a type of anti-inflammatory medicine. They work by helping to reduce the sensitivity in the airways. There are many side effects from long-term use of oral corticosteroids.
  • Biological medications –There is a growing list of biological medications that are available for use for asthma. Biological medications are usually used when other treatments aren’t working and they target specific cells to prevent symptoms from occurring – they don’t just treat the symptoms to relieve discomfort. The medication is given by injection, usually in the doctor’s office or clinic.
    • Monoclonal antibodies [10] are a type of biological medication for severe uncontrolled asthma. They work by blocking the activity of immune system chemicals that trigger airway inflammation.

What are the newest asthma treatments?

As medical professionals work to find the best way to treat asthma, new approaches to treatment become available.

Anti-Inflammatory Reliever = AIR
In this approach, an inhaled corticosteroid (ICS) is combined with a reliever medication. The corticosteroid reduces lung inflammation
while the reliever medication provides quick relief by opening up your airways. [11]

Maintenance And Reliever Therapy with ICS-formoterol = MART
MART is a combination inhaler that combines a low-dose of ICS-formoterol for your maintenance treatment with a bronchodilator for
symptom relief. [12]

In some cases, bronchial thermoplasty [13] might be recommended. This is a procedure where a flexible tube is passed through the airways into the lungs to deliver a special form of heat treatment. The heat shrinks smooth muscle to prevent it from tightening and triggering asthma attacks. This is usually a single-day treatment done with a local anesthetic, but it may involve several sessions.

A woman coughing

What are lifestyle changes to help severe asthma?

As well as medication, there are lifestyle changes [14] that can help you live well with asthma.

  • Quit smoking. Smoking is a major risk factor for asthma attacks, as well as being associated with numerous other health problems. If you smoke and have asthma, you should try to quit. Seek help from your doctor, nurse or a smoking cessation group to help make the change.
  • Maintain a healthy weight and exercise routine. If you’re taking long-term high doses of oral corticosteroids, they can increase appetite and cause weight gain. It can be difficult to manage your weight with severe asthma, as your symptoms may make activity more difficult, and you may lack energy and motivation if you’re feeling unwell. But by making even small changes to your diet and activity levels, you can make a difference.
  • Do breathing exercises. Regularly practicing breathing exercises can be beneficial as they help to improve lung capacity, strength, and health. There are various methods suitable for people with asthma – some of which are taught by experts or physiotherapists – and they’re easy to learn and practice at home.
  • Reduce your stress levels. To reduce stress – which can be a key trigger for asthma – incorporating yoga, meditation, or mindfulness practice into your lifestyle may be helpful.

At the start of flu season each year, it is important to get a flu vaccination. Flu affects the respiratory system, can cause pneumonia, and can lead to or worsen asthma attacks. It can also be life threatening for someone with severe asthma. [15] It is important to choose the shot, not a nasal spray, which may trigger your asthma symptoms.

Before making any lifestyle changes, it is a good idea to discuss this with your doctor or
asthma nurse first. This will allow them to recommend additional support and advise any modifications to meet your specific needs. Your friends, family, and employer can also act as advocates, helping you to make adjustments to your home and work life.

What are some useful treatment tools for severe asthma?

How can I prevent and manage severe asthma?

Alongside taking your medication as prescribed, the best way to reduce the risk of severe asthma attacks and worsening symptoms is to avoid triggers as much as possible.

As part of your Asthma Management Plan [16], it’s important to monitor your severe asthma symptoms. It’s useful to keep a written record of your symptoms, when they occur, and any triggers you notice. For example, your symptoms might be triggered by environmental factors, such as seasonal pollen. For women, a change in hormone levels may make symptoms worse.

By spotting patterns, you can learn to take action before symptoms worsen. A record can also act as a form of encouragement, highlighting how things have improved over time. This log is also useful to show your asthma nurse or doctor at appointments.

Booklet with pen

Resources

Severe asthma_infographic
Citations:
  1. What is severe asthma? Asthma + Lung UK. Published November 30, 2022. Accessed April 8, 2024. https://www.asthmaandlung.org.uk/conditions/severe-asthma/what-severe-asthma
  2. Rönnebjerg L, Axelsson M, Hannu Kankaanranta, et al. Severe Asthma in a
    General Population Study: Prevalence and Clinical Characteristics. Journal of
    Asthma and Allergy. 2021;Volume 14:1105-1115.
    doi:https://doi.org/10.2147/jaa.s327659
  3. American Lung Association. Severe Asthma. Lung.org. Published 2024.
    Accessed April 8, 2024. https://www.lung.org/lung-health-diseases/lung-disease-
    lookup/asthma/learn-about-asthma/types/severe-asthma
  4. Bronchial hyperreactivity (BHR): An old but gold hallmark of asthma.
    Heraldopenaccess.us. Published 2023. Accessed April 9, 2024.
    https://www.heraldopenaccess.us/openaccess/bronchial-hyperreactivity-bhr-an-
    old-but-gold-hallmark-of-asthma
  5. Team A. Learn To Recognize the Symptoms of Silent Asthma. Allergy & ENT
    Associates. Published September 9, 2022. Accessed April 9, 2024.
    https://www.aentassociates.com/learn-to-recognize-the-symptoms-of-silent-
    asthma/
  6. Aaaai.org. Published 2024. Accessed April 9, 2024.
    https://www.aaaai.org/Aaaai/media/MediaLibrary/Images/Journals/19-00025-
    ASSESS-graphical-abstract-resized.jpg
  7. https://www.facebook.com/AsthmaCanada. Airway Remodelling Explained –
    Asthma Canada. Asthma Canada. Published 2024. Accessed April 9, 2024.
    https://asthma.ca/airway-remodelling-explained/
  8. ‌NHS Choices. Treatment – Asthma. Published 2024. Accessed April 9, 2024.
    https://www.nhs.uk/conditions/asthma/treatment/
  9. ‌‌Taking theophylline for asthma. Asthma + Lung UK. Published September 30,Accessed April 9, 2024. https://www.asthmaandlung.org.uk/symptoms-tests-treatments/treatments/theophylline
  10. ‌‌Biologic therapies for severe asthma. Asthma + Lung UK. Published November
    30, 2023. Accessed April 9, 2024. https://www.asthmaandlung.org.uk/symptoms-
    tests-treatments/treatments/biologic-therapies
  11. ‌AIR (anti-inflammatory reliever). Asthma + Lung UK. Published February 29, Accessed April 9, 2024. https://www.asthmaandlung.org.uk/symptoms- tests-treatments/treatments/air
  12. ‌Maintenance and Reliever Therapy (MART). Asthma + Lung UK. Published
    September 7, 2023. Accessed April 9, 2024.
    https://www.asthmaandlung.org.uk/symptoms-tests-treatments/treatments/mart
  13. ‌https://www.asthmaandlung.org.uk/symptoms-tests-treatments/treatments/air
  14. Lifestyle Changes to Manage Asthma. Allergy & Asthma Network. Published
    February 5, 2024. Accessed April 9, 2024.
    https://allergyasthmanetwork.org/what-is-asthma/lifestyle-changes-to-manage-
    asthma/
  15. Flu Vaccine among Adults with Current Asthma. Published 2024. Accessed April
    9, 2024. https://www.cdc.gov/asthma/asthma_stats/flu-vaccine-among-adults-
    with-current-asthma.html
  16. Asthma Action Plan. Asthma & Allergy Foundation of America. Published March
    22, 2024. Accessed April 9, 2024. https://aafa.org/asthma/asthma-
    treatment/asthma-treatment-action-plan/