Asthma: the difference between controlling the disease and managing the symptoms

What happens in the airways during an asthma attack?

Asthma is a chronic inflammatory disease of the airways, the tubes that carry air in and out of the lungs. In someone with asthma, the airway walls are persistently inflamed even when there are no symptoms. When a trigger is encountered, such as dust, cold air, smoke, or physical exertion, the inflamed walls swell further, the muscles around the airway contract, and the lining produces excess mucus. All three changes narrow the tube and make breathing difficult.

The wheeze that accompanies an attack is the sound of air being forced through a narrowed tube. The sensation of tightness in the chest and the characteristic difficulty breathing out (rather than in) are the result of this narrowing. A dry cough, especially at night, is another common feature because the airway becomes more reactive when lying down.

Asthma varies enormously between individuals. Some people are triggered mainly by exercise, others by respiratory infections, others by allergens. Understanding your specific triggers is the foundation of good asthma management, because avoiding what starts a reaction is as important as treating the underlying inflammation.

Dust storms and air pollution: why asthma is harder to control regionally

Dust storms carry fine particulate matter that penetrates deep into the lungs and triggers an acute inflammatory response, particularly in people with asthma. A 2025 study published in Scientific Reports found a clear association between high-dust days and increased hospital visits for respiratory illness. A 2015 study in the European Respiratory Journal found that children's exposure to natural dust events was associated with measurably increased asthma medication purchases.

Beyond dust storms, shisha smoke is a potent airway irritant that is common in indoor social settings across the region, and it affects people nearby as well as those smoking. Vehicle exhaust in dense urban traffic, and waste burning in areas without reliable waste collection services, add to the cumulative burden on airways that are already more reactive.

Practically: check air quality and dust forecasts before outdoor activities. On heavy dust days, staying indoors with windows closed is the most effective single measure. An N95 mask offers meaningful protection if you must go outside. If you work outdoors, discuss a specific action plan for dust days with your doctor, including whether to take a preventive dose of reliever inhaler before shifts.

Reliever versus controller inhaler: the most common mistake in asthma

This single misunderstanding is behind more poorly controlled asthma than any other factor. Many patients use their reliever inhaler, typically salbutamol (Ventolin), daily and consider this normal. In fact, needing a reliever inhaler more than twice a week is a recognised signal that asthma is not controlled, and should prompt a review rather than continued use.

The reliever inhaler works within minutes by relaxing the muscle around the airway, but it does nothing to treat the underlying inflammation that makes the airway hypersensitive in the first place. The controller inhaler, which contains inhaled corticosteroid, addresses that inflammation. It must be taken daily, even when there are no symptoms, because its benefit builds over days and weeks. A 2025 study in Internal Medicine Journal confirmed that better patient understanding of this distinction correlates directly with better treatment adherence and improved asthma control.

The inhaled corticosteroid in a controller inhaler is fundamentally different from oral or injected steroids. The amount reaching the bloodstream is tiny, and the risks associated with long-term oral steroids (such as adrenal suppression, bone loss or weight gain) are not a meaningful concern at standard inhaled doses. The one real precaution is rinsing the mouth after each use to prevent oral thrush.

How to use a pressurised MDI inhaler correctly

A large proportion of inhaler users make technique errors that result in most of the medication depositing in the mouth and throat rather than reaching the lungs. A review published in Annals of Allergy and Asthma in 2016 found that inhaler technique errors are extremely common and directly reduce medication effectiveness. Correcting technique is often the single highest-yield intervention before escalating treatment.

The most common errors are inhaling too fast, which causes most of the particles to impact the back of the throat, and poor coordination between pressing the inhaler and starting to breathe in. Both problems are substantially solved by using a spacer device, which holds the aerosol in a chamber allowing a slower, more controlled breath. Spacers are recommended for all patients and are essential for children and older adults.

Even with correct technique, remember to shake the inhaler for five seconds before each use, and to check the dose counter if your inhaler has one. An empty inhaler can still produce a puff that feels real but contains no medication.

Common triggers and how to manage them in a regional setting

Every person with asthma has their own trigger profile. House dust mites are particularly problematic in warm humid environments. Pollen levels peak in spring across the Levant and parts of the Gulf. Mould grows in bathrooms and kitchens with poor ventilation, which is common in older housing stock. Pet dander from cats, which is an extremely common household pet across the region, is frequently overlooked as a trigger.

Exercise is a trigger for a significant minority of patients, but this is not a reason to avoid activity. Taking two puffs of reliever inhaler 15 minutes before exercise, warming up gradually rather than starting intensely, and breathing through the nose during moderate activity all reduce exercise-induced symptoms. Good baseline control with a controller inhaler reduces exercise-induced bronchoconstriction substantially.

Some medications can trigger asthma attacks in susceptible individuals. Aspirin and non-steroidal anti-inflammatory drugs such as ibuprofen affect approximately 10 to 20 percent of adults with asthma. Beta-blocker medications, used for blood pressure and heart conditions, can also worsen asthma. Always tell any healthcare provider that you have asthma before starting a new medication.

Peak flow monitoring: tracking your asthma at home

A peak flow meter is a simple, inexpensive device that measures how fast you can push air out of your lungs. You blow into it as hard and fast as possible, and it gives a reading in litres per minute. Your personal best, measured over two weeks when your asthma is well controlled, becomes your reference. Readings above 80 percent of your personal best are in the green zone (safe), between 50 and 80 percent signal a yellow zone warning requiring additional medication, and below 50 percent is a red zone requiring urgent medical attention.

Peak flow monitoring is most valuable for people who have difficulty sensing when their asthma is worsening, or those with severe asthma in whom symptoms alone do not reliably indicate severity. Daily readings create a trend that allows your doctor to adjust your treatment before a crisis develops.

In parts of the region, peak flow meters may not be available in small pharmacies. Hospital pharmacies and specialist respiratory clinics are more reliable sources. If unavailable locally, the principles of recognising worsening asthma (increasing reliever use, night waking, reduced exercise tolerance) remain valid guides even without the device.

Asthma during Ramadan and Hajj: specific challenges

During Ramadan, some patients stop their controller inhaler in the mistaken belief that inhaling medication breaks the fast. Scholarly opinion on this varies, and dry powder inhalers in particular are considered permissible by many Islamic scholars because the amount swallowed is negligible. Discuss both the religious and medical aspects with your own religious authority and your doctor. Stopping a controller inhaler during Ramadan significantly increases the risk of attacks.

Hajj and Umrah present a specific combination of challenges: extreme heat, vast crowds, respiratory infections circulating among pilgrims, incense smoke in some areas, and the physical exertion of walking long distances. The meningococcal vaccine is compulsory, but you should also ensure your asthma is in the best possible control before travel, carry sufficient medication for the full trip plus a reserve, and have a written action plan that you can show to a medical team if needed.

Pregnancy does not change the fundamental treatment approach. Inhaled corticosteroids are considered safe in pregnancy by all major guidelines. The risk of uncontrolled asthma to both mother and fetus is significantly greater than any risk from standard inhaled treatment. If you are pregnant and have asthma, maintain your controller treatment and attend all scheduled reviews.

Asthma severity and stepping up treatment

Asthma is classified by severity, and treatment is matched to that severity and adjusted over time. Mild intermittent asthma, meaning symptoms less than twice a week with no night waking, can often be managed with a reliever inhaler alone. Mild persistent asthma, where symptoms are more frequent, requires a low-dose inhaled corticosteroid taken daily. More severe or frequent symptoms call for higher doses and combination inhalers that include both a corticosteroid and a long-acting bronchodilator in a single device.

The Global Initiative for Asthma (GINA) guidelines recommend a stepwise approach: start with the treatment appropriate to the current severity and step up if control is poor after four to eight weeks. Crucially, the guidelines also recommend stepping down once good control has been maintained for three months, to find the minimum effective dose.

Biological therapies targeting specific allergy or inflammatory pathways are now available for severe uncontrolled asthma and are offered in specialist centres in Saudi Arabia, UAE and Egypt. If your asthma remains poorly controlled despite optimal inhaled therapy and confirmed good technique, ask for a referral to a respiratory specialist for assessment.

When to see your doctor about asthma control

Well-controlled asthma does not require frequent urgent visits, but there are specific situations that warrant a review appointment rather than waiting. If you have been using your reliever inhaler more than twice a week for two or more consecutive weeks, if symptoms are waking you at night, if you have had to change your normal activities because of asthma, or if you have used a course of oral steroids, these are all signals that your current regimen needs adjustment.

A written asthma action plan prepared with your doctor tells you precisely what to do at each level of symptom severity: what to take, how much, and when to call for help or go to hospital. If you do not have a written plan, ask your doctor to prepare one with you at the next appointment. This plan is especially important in the regional context where reaching specialist care may take time.

Asthma that is difficult to control despite good technique and adherence to treatment deserves specialist evaluation. Uncontrolled severe asthma now has additional treatment options including biological agents targeting specific inflammatory pathways. These are available in several regional hospital centres and your doctor can refer you if standard treatment is insufficient.

Sources

• Yitshak-Sade M, Novack V, Katra I et al: Non-anthropogenic dust exposure and asthma medication purchase in children, The European respiratory journal, 2015
• Hamidian M, Jor A, Keikhaie KR et al: Dust air pollution and hospital visits for respiratory, cardiovascular, and eye diseases in Eastern Iran, Scientific reports, 2025
• Geravandi S, Sicard P, Khaniabadi YO et al: A comparative study of hospital admissions for respiratory diseases during normal and dusty days in Iran, Environmental science and pollution research international, 2017
• Nelson HS: Inhalation devices, delivery systems, and patient technique, Annals of allergy, asthma and immunology, 2016
• Celebi Sozener Z, Aydin O, Celik GE et al: Effect of adherence on asthma control: more patient knowledge, more adherence, more control, Internal medicine journal, 2025
• Alsharairi NA: Diet and Food Allergy as Risk Factors for Asthma in the Arabian Gulf Region: Current Evidence and Future Research Needs, International journal of environmental research and public health, 2019
• Global Initiative for Asthma (GINA): Global Strategy for Asthma Management and Prevention, 2024