“My blue inhaler works” is not reassurance. It is the single most reliable warning sign that somebody is heading for the attack that kills them.

The four questions, and the sentence to take with you

These are the questions an asthma review asks, and most people have never been asked them in a row. Answer honestly — nothing is stored — and the tool assembles a sentence you can read out or hand over at an appointment. That sentence is the useful output, not the score.

Two inhalers doing opposite jobs

Most asthma harm comes from a single misunderstanding: that the inhaler which makes you feel better is the one treating the disease. It is not. Colours vary by country and brand, so the words on the box matter more than the colour.

• Needing the reliever more than twice a week — not counting before exercise if that is your plan — means the preventer is not doing its job, or is not being taken, or the technique is wrong. Any of those is fixable, and none of them fixes itself.
• More than two reliever canisters in a year is a documented risk marker for death. Pharmacies and prescription records can see it; most patients have never been told the number matters.
• Some countries and guidelines now combine both jobs in one inhaler taken as needed and as maintenance. If that is your prescription, follow it exactly — the point of this section is not which regimen you are on, but that reliever-only asthma treatment is the dangerous one.
• Nobody should be on reliever alone. If your only inhaler is the blue one, that is the appointment to book this week, whatever else you take away from this page.

What an attack actually looks like

The picture people expect is dramatic wheezing. The dangerous picture is quieter than that, and the quietest version is the worst one.

• Cannot complete a sentence in one breath. This is the single most useful bedside sign there is, it needs no equipment, and it means the attack is severe.
• The reliever is not lasting four hours, or is not working at all. A reliever that stops working is an emergency, not a reason to keep using it.
• Sitting forward, using the neck and shoulder muscles to breathe, unable to lie down, too breathless to eat or talk. In small children, watch for the belly and ribs pulling in with each breath, flaring nostrils, grunting, or a child who has gone quiet and floppy.
• A silent chest is not improvement. When the wheeze disappears because too little air is moving to make a sound, the person is close to respiratory arrest. Exhaustion, drowsiness, confusion and blue lips are the same message.
• A rising pulse and a rising respiratory rate track the severity better than how the person says they feel. Somebody with severe asthma can look eerily calm because they are running out of the energy to look distressed.
• Attacks build over hours to days more often than in seconds. The day before is usually recognisable in hindsight: more reliever, worse nights, a cold that went to the chest.

The written action plan

A personal written plan roughly halves the risk of an admission, takes ten minutes to fill in with a clinician, and most people with asthma do not have one. It is the single highest-yield thing to ask for.

• What your usual medicines and doses are, in writing, because nobody remembers accurately in a crisis and neither does a family member.
• What to do when things get worse — how much reliever, whether to increase or start anything, and at what point to ring.
• The named thresholds for an emergency: reliever not lasting, cannot speak a sentence, peak flow below a number that is yours rather than a textbook average.
• Who to contact, in and out of hours, written down rather than looked up while frightened.
• A rescue steroid plan if you are the sort of patient who needs one, and an explicit instruction about when it applies — not a vague permission.
• Your own peak flow numbers, if you use a meter. A plan built on your personal best is far more useful than one built on a predicted average: it turns “I feel worse” into a number, and it is how a plan can say exactly when to increase treatment and when to ring. Ask for a meter and for the two or three numbers that matter to be written on the plan.
• A copy in three places: your phone, your fridge, and with whoever is likely to be with you. For a child, that means school and every regular carer.

Why the medicine “does not work”

Study after study finds that most people use their inhaler wrongly, which means the dose ends up in the mouth and throat instead of the lungs. This is the cheapest fix in the entire subject and it is almost never checked.

1. Use a spacer with a metered-dose inhaler, the kind you press. It roughly doubles what reaches the lungs, removes the need for perfect timing, and is not just for children — adults having an attack should be using one too.
2. Shake, one puff at a time, slow and steady breath — not a hard fast suck. With a spacer, breathe normally from it four or five times after each puff. With a dry-powder inhaler the opposite applies: a quick, deep, forceful breath.
3. Never fire several puffs into a spacer at once. The doses stick to the plastic and to each other; one puff, breathe, then the next.
4. Rinse your mouth after a steroid inhaler to avoid thrush and a hoarse voice, which are among the reasons people quietly stop taking it.
5. Check the counter, and check it is not empty. Shaking and floating in water tell you nothing. An inhaler that fires when it is empty is a common reason an attack “did not respond”.
6. Wash the spacer monthly in warm soapy water and let it air-dry — do not rub it dry, because static reduces the dose that gets through.

Steroid tablets, and the week after an attack

• A short course of steroid tablets is the treatment for a real attack, and finishing it matters. Stopping early because you feel better is how the attack returns a few days later, often worse.
• Every course of steroid tablets is a flag, not just a treatment. Two or more courses in a year means the underlying plan is not working, and that is a reason to change something rather than to be relieved it worked again.
• Keep taking the preventer during and after an attack. People routinely stop the daily inhaler while on tablets, which is exactly backwards.
• Book the review within a week or two of any attack — ideally within 48 hours of leaving hospital. This is the appointment that most reliably prevents the next one, and it is the one most often skipped because the person feels fine again.
• Expect the review to change something: the preventer dose, the device, the technique, the plan, the trigger avoidance, or a referral. A review that changes nothing after an attack has not really happened.
• Frequent steroid courses have their own costs — bones, sugar, mood, eyes — which is an argument for better control rather than for avoiding treatment when it is needed.

Triggers, ranked by how often they actually matter

Children, school and the things parents are told wrongly

• A child with asthma should have a spacer, and use it, for both the daily preventer and the emergency routine. Direct puffs into a small mouth mostly land on the tongue.
• School and childcare need a copy of the plan and their own reliever, plus permission and knowledge to use it. Ask what happens if your child needs an inhaler during a school trip, and get the answer in writing.
• Fear of inhaled steroids costs more than the steroids do. The effect on growth from inhaled preventers is small and mostly early; the effect of undertreated asthma is missed school, admissions and occasionally death. Ask for the lowest dose that keeps control, not for no dose.
• Coughing at night, or a cough that always follows exercise, is often the whole presentation in a child, and it gets treated as a series of infections for years.
• Watch the ribs and belly, not the wheeze. In small children, indrawing under the ribs, flaring nostrils, grunting, feeding poorly and unusual quietness are the severe signs.
• Teenagers are the highest-risk group for death, because control slips exactly when supervision does. The useful move is not more nagging but a plan the teenager owns, a device they will actually carry, and one adult who asks the four questions without drama.

Pregnancy, and the risk people get backwards

• Undertreated asthma is more dangerous to a pregnancy than asthma medicines are. Poor control is associated with low birth weight, prematurity and pre-eclampsia; the usual inhalers are considered safe and are continued deliberately.
• Roughly a third of women get worse, a third better and a third stay the same, so it needs watching rather than assuming.
• Attacks in pregnancy are treated as urgently as any other, including steroid tablets when they are needed. The oxygen matters to the baby more than any theoretical medicine risk.
• Say you are pregnant early in any asthma consultation, and ask for the plan to be reviewed rather than quietly reduced.
• Nobody should stop a preventer because they are pregnant without that being an explicit, discussed decision with the person looking after the pregnancy.

If you are with somebody having an attack

• Do the counting for them. Somebody in an attack cannot easily track ten puffs at thirty-second intervals, and the counting also slows their breathing down.
• Stay, and say you are staying. Panic makes the attack worse and being left alone makes the panic worse. Calm narration is a treatment here.
• Do not put them in a car to drive to hospital themselves, and do not encourage walking anywhere. An ambulance brings oxygen and can treat them on the way.
• Say the word asthma when you call, plus whether the reliever is working and whether they can speak in sentences — that is the information which sets the priority.
• Afterwards, help them get the review. The single most useful thing a friend or partner does is make sure the appointment happens in the week after, when the person feels well and no longer wants to bother anybody.
• If they stop breathing or become unresponsive, call the emergency number and start chest compressions. That is rare, and it is the reason none of this waits for a second opinion.

The drill: 16 decisions

Sixteen ordinary moments — a fourth canister this year, a night cough, a school trip, a chest that has gone quiet. Most have an instinctive answer that has killed people. Pick your move; every answer explains why.

The card

Print it for the fridge, the school bag and the wallet.

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