What Is Allergic Asthma?
Asthma is a chronic inflammatory airway disease characterised by reversible airflow obstruction, airway hyperresponsiveness, and airway remodelling. Allergic asthma is the most common subtype — approximately 60–80% of asthmatics have allergic sensitisation. In India, asthma affects an estimated 30–35 million people, and allergic asthma predominates especially in children and young adults.
Despite being a controllable disease, asthma causes significant avoidable morbidity and mortality in India — largely due to inhaler phobia, steroid fear, and reliance on bronchodilators alone without anti-inflammatory treatment.
Why “Allergic” Asthma?
In allergic asthma, exposure to an allergen triggers a Type 2 inflammatory response (involving IgE antibodies, mast cells, and eosinophils) that causes bronchospasm (airway narrowing), mucus production, and airway swelling. The same allergens that cause allergic rhinitis — house dust mites, cockroach allergen, moulds, and pollens — are the major triggers of allergic asthma in India.
Symptoms of Asthma
- Recurrent wheezing — a high-pitched whistling sound while breathing out
- Breathlessness — especially on exertion, at night, or early morning
- Chest tightness
- Cough — particularly nocturnal cough (waking at night with cough) or chronic cough without obvious cause
Key characteristic: symptoms are episodic and reversible — they worsen with triggers and improve with bronchodilators or spontaneously. Symptoms are often worse at night and early morning (circadian pattern of airway inflammation).
Common Asthma Triggers in India
- Allergens: House dust mites, cockroach allergen, moulds (especially Aspergillus), pollen, pet dander
- Respiratory infections: Viral upper respiratory infections (the most common trigger for asthma attacks in children and adults)
- Air pollution: Vehicle exhaust, industrial pollution, crop burning (massive problem in North India during October-November)
- Indoor air pollution: Cooking smoke from biomass fuels (still used in rural India), incense sticks (agarbatti), mosquito coils
- Exercise: Exercise-induced bronchoconstriction — especially in cold/dry air
- Medications: Aspirin and NSAIDs (aspirin-exacerbated respiratory disease), beta-blockers
- Occupational exposures: Flour dust (bakers), isocyanates, latex, chemicals
- Emotions/stress: Can trigger or worsen attacks
Diagnosis of Asthma
- Spirometry with bronchodilator reversibility test — the cornerstone of diagnosis. FEV1 increasing by ≥12% (and ≥200mL) after salbutamol indicates reversible obstruction consistent with asthma
- Peak expiratory flow (PEF) monitoring — home peak flow meters show diurnal variation >20% in asthma
- FeNO (Fractional exhaled Nitric Oxide) — a breath test measuring eosinophilic airway inflammation. Available at major centres. Elevated FeNO (>25ppb) suggests allergic asthma and predicts steroid response.
- Skin prick testing / specific IgE — to identify allergen sensitisation
- Blood eosinophil count and total IgE — markers of type 2 inflammation
Asthma Severity Classification
Asthma is classified by symptom frequency and lung function into: intermittent, mild persistent, moderate persistent, and severe persistent. Treatment is stepped up or down based on control.
Treatment of Allergic Asthma
Inhalers — The Foundation of Treatment (And Why They’re NOT Dangerous)
The cornerstone of asthma treatment is inhaled medication — which delivers the drug directly to the airways at very low doses, minimising systemic side effects. Inhaler phobia is the single biggest barrier to asthma control in India.
- Inhaled corticosteroids (ICS) — budesonide, beclomethasone, fluticasone — the most important anti-inflammatory treatment. Used daily as controller therapy. At prescribed doses, negligible systemic absorption. Inhaler steroids are NOT the same as anabolic steroids, and NOT like oral steroids — they are fundamentally safer.
- Short-acting beta-agonists (SABA) — salbutamol (albuterol) — the blue “reliever” inhaler. Used only for acute symptoms, NOT as regular therapy. Overuse of SABA without ICS is dangerous and associated with asthma deaths.
- Long-acting beta-agonists (LABA) — formoterol, salmeterol — always used in combination with ICS, never alone
- LAMA (tiotropium) — add-on for inadequately controlled asthma
- SMART therapy — a single inhaler (budesonide-formoterol) used for both maintenance and relief — now recommended by GINA as preferred approach for most patients
Inhaler Technique Is Critical
80% of Indian asthma patients use their inhalers incorrectly, rendering treatment ineffective. Ask your doctor or nurse to demonstrate proper MDI or DPI technique. A spacer device significantly improves drug delivery with MDI inhalers — every asthmatic should own one.
Leukotriene Receptor Antagonists
Montelukast (singulair) — oral tablet, add-on therapy. Particularly useful in aspirin-sensitive asthma, allergic rhinitis coexisting with asthma, and exercise-induced asthma.
Biologics for Severe Allergic Asthma
For patients with severe, uncontrolled allergic asthma despite maximum inhaler therapy:
- Omalizumab (anti-IgE) — for patients with high IgE and allergen sensitisation. 4-weekly injection. Available in India.
- Mepolizumab, benralizumab, dupilumab (anti-IL-5/IL-4/13) — for eosinophilic severe asthma
Allergen Immunotherapy for Asthma
For patients with mild-moderate allergic asthma who are sensitised to dust mites or grass pollen, AIT (subcutaneous injections or sublingual drops) is a disease-modifying option that reduces exacerbations and medication requirements over time.
Asthma Action Plan
Every asthma patient should have a written action plan specifying: daily controller medications, how to recognise worsening, what to do in a flare (step up reliever, add steroids), and when to go to hospital. Use peak flow zones (green/yellow/red) for objective guidance.
Asthma in Children in India
Childhood asthma is common but frequently undertreated in India because parents fear inhalers “will make the child dependent” or “contain steroids.” The risks of untreated asthma (airway remodelling, lung development impairment, life-threatening attacks) far outweigh the minimal risk of low-dose ICS. Early, adequate treatment gives children the best chance of outgrowing asthma.
FAQs About Asthma in India
Will I become dependent on inhalers?
No — asthma inhalers are not addictive. Properly treated asthma may allow step-down of treatment over time. What happens is that when asthma is well controlled, patients often try to stop treatment — and then have attacks.
Can I exercise with asthma?
Yes — with proper treatment, most asthmatics exercise normally. Take a SABA puff 15 minutes before exercise if needed. Swimming is particularly well-tolerated.
Is asthma hereditary?
There is a strong genetic component — if a parent has asthma or allergies, children have higher risk. But environment and allergen exposure are important modifiable factors.
Written by Dr. Keerthivardhan, Clinical Immunologist, NIMS Hospital Hyderabad.