Asthma in Pakistan: count the canisters, not the inhalers
One salbutamol canister a month raises mortality — and it is sold over the counter here. The national guideline's SABA-free switching table, the exacerbation algorithms, the steroid and nebuliser myths, and the guideline's own admission that its central recommendation is an extrapolation.
Ask an asthma patient in Pakistan whether they use an inhaler and they will say yes. Ask how many salbutamol canisters they get through and you will find out whether they are safe.
The Pakistan Chest Society's 2026 asthma guideline puts numbers on it: three or more 200-dose canisters a year increases the risk of exacerbation, and one canister a month or more increases mortality. Salbutamol here is cheap, sold across the counter without a prescription, and refilled without anyone counting. It is entirely possible for a patient to be on their fourteenth canister of the year and describe their asthma as "controlled, I just keep the inhaler with me".
What replaced it
The guideline's core move is away from salbutamol as a reliever altogether. Three terms are worth getting exactly right, because they are not interchangeable:
- Maintenance treatment — taken every day on a schedule, even with no symptoms. ICS, ICS-LABA, ICS-LABA-LAMA, LTRA, biologics.
- Anti-inflammatory reliever (AIR) — an inhaler containing low-dose ICS plus a rapid-acting bronchodilator, taken when needed. It can also be used before exercise or allergen exposure.
- Maintenance-and-reliever therapy (MART) — one ICS-formoterol inhaler used as both. SMART is the same thing.
Two combinations are never allowed, and they are easy to create by accident when a patient collects prescriptions from more than one doctor:
- ICS-formoterol must never be the reliever alongside a maintenance ICS-LABA that is not formoterol.
- ICS with a non-formoterol LABA, and ICS-SABA, cannot be used as MART at all.
The switching table
Adapted by the guideline from the joint BTS/NICE/SIGN guideline NG245, for adults and children 12 and over:
| Current treatment | Switch to |
|---|---|
| SABA only | Low-dose ICS-formoterol as needed (AIR) |
| Regular low-dose ICS, or low-dose ICS-LABA, with SABA as needed — with or without LTRA or LAMA | Low-dose MART |
| Regular moderate-dose ICS, or moderate-dose ICS-LABA, with SABA as needed — with or without LTRA or LAMA | Moderate-dose MART |
| Any high-dose ICS-containing regimen | Refer to specialist asthma care |
And a restraint clause that is easy to miss: identify the patients who can be switched, particularly where asthma is not controlled — but if they are asymptomatic and happy on their current pathway, it is not recommended that they be transferred. This is a guideline telling you when to leave something alone.
For a patient presenting for the first time on no asthma medicine at all, the choice depends on symptom severity, and the SABA-free pathways — AIR or MART — are the recommended starting point.
The consultation before the pharmacology
The guideline devotes a whole table to myths, because they "lead to confusion, stigma, and sometimes even harmful decisions about treatment". Anyone who has run an outpatient clinic in Pakistan will recognise most of them:
| What you will hear | What to say |
|---|---|
| Inhaled steroids are addictive | They are safe and not habit forming. |
| Inhaled steroids are harmful | An inhaler delivers a very small amount of steroid. |
| Asthma can be managed with a salbutamol inhaler alone | Asthma is a disease of inflammation, not bronchoconstriction alone. Salbutamol does not treat inflammation. |
| Asthma medicines are only for when you have symptoms | They are taken even when asymptomatic — that is how they prevent exacerbations. |
| Nebulisers are better than inhalers | Inhalers are easier to use and as efficient. Many controller medicines cannot be given by nebuliser at all. |
| Spacers are only for children | They matter at every age — they get the drug to the lungs instead of the mouth and throat. |
| People with mild asthma cannot die of it | Any severity can exacerbate, mildly or severely. |
The nebuliser one deserves particular attention, because it drives real behaviour: patients who believe a nebuliser is stronger will present to a clinic for one rather than use the inhaler they own, and will treat the inhaler as the weaker, optional therapy.
Who is at risk of dying
The guideline asks that any of these be documented in the notes, and the patient told to seek urgent help early:
- History of near-fatal asthma
- Emergency visit or hospitalisation for asthma in the past year
- Recent or current oral corticosteroid use
- Not currently on ICS
- SABA overuse
- Non-compliance with ICS-containing medication
- Poor adherence to, or absence of, a written action plan
- Psychosocial problems
- Food allergy
- Comorbidities — pneumonia, arrhythmia, diabetes
The attack
Classify before you treat. Mild or moderate: talks in phrases, prefers sitting to lying, not agitated, respiratory rate raised, no accessory muscle use, pulse 100–120, SpO₂ 90–95%, PEF above 50% of predicted or best. Severe: talks in words, sits hunched forward, agitated, respiratory rate above 30, using accessory muscles, pulse above 120, SpO₂ below 90%, PEF 50% or less. Life-threatening: drowsy, confused, quiet chest.
In primary care, mild to moderate gets SABA 4–10 puffs by pMDI with a spacer every 20 minutes for three doses, prednisolone if moderate, and oxygen. Severe and life-threatening get transferred — with SABA, ipratropium, systemic corticosteroids and oxygen given while the transfer is arranged. Target saturation is 93–95% in adults and 94% or above in children.
In the emergency department, severe adds intravenous magnesium 2 g over 20 minutes. Life-threatening goes to ICU.
Oral steroids: adults 40–50 mg/day for 5–7 days; children 0.5 mg/kg/day to a maximum of 40 mg, for 3–5 days. No taper is needed under two weeks. On discharge: reliever as needed, start or step up ICS on the MART pathway, check inhaler technique and compliance, and follow up within 2–7 days — 1–3 days for children.
What the guideline admits about its own evidence
This is the paragraph that makes the guideline worth reading rather than skimming:
While MART with ICS–formoterol has gained widespread acceptance internationally for asthma management, there is a notable absence of robust clinical data from Pakistan… The management strategy recommended in current guidelines is an extrapolation of conclusions drawn from large-scale studies done in western and other Asian countries.
A national society labelling its own central recommendation an extrapolation is unusual, and it is the honest position. It does not make MART the wrong choice — the regional evidence is real. SMARTASIA, a multi-country Asian real-world study, found budesonide-formoterol as maintenance and reliever in a single inhaler improved control scores against the same drug twice daily plus separate salbutamol. The COSMOS Asian sub-analysis found 38% fewer exacerbations. A Chinese paediatric cohort found MART had lower exacerbation rates and was cost-effective.
What it does mean is that the confidence attached to MART here should sit a notch below the confidence attached to it in London — and that Pakistani trial data is a gap somebody should fill.
Bottom line
Count the canisters, not the inhalers. Move salbutamol-only patients to an anti-inflammatory reliever, and ICS-plus-SABA patients to MART — unless they are well and content, in which case leave them be. Never pair ICS-formoterol as reliever with a non-formoterol maintenance LABA. Correct the steroid and nebuliser beliefs before you argue about doses, because a patient who thinks their preventer is addictive will not take it whatever you prescribe. And in a severe attack in the emergency department, remember the magnesium.
Our asthma pathway has the full switching table, the ICS dose bands, both exacerbation algorithms and the complete myths table in one place. Its sibling is the COPD pathway, which covers the other half of the chest clinic — including obstruction after tuberculosis.
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