34 Million Indians Suffer From Asthma: Pulmonologist Urge Shift To Safer, Modern SMART Treatment Strategies

A staggering 34 million people in India suffer from asthma - a chronic lung condition where airways become inflamed and produce excess mucus, making breathing difficult. This account for nearly 13 per cent of the global prevalence, according to the Global Burden of Disease Study.

What is more concerning is that, India’s rates of mortality and disability-adjusted life years (DALYs) due to asthma are threefold and twofold higher, respectively, than global averages. These alarming figures stem from significant challenges in timely diagnosis and appropriate inhaled therapy, Dr. Vijay Kumar Agarwal, Head of Pulmonology and ICU Department at Yatharth Super Speciality Hospital, Faridabad, pointed out.

Add to this is the continuation of conventional treatment approaches. Despite advances in clinical guidelines and treatment options, a substantial number of asthma patients continue to rely exclusively on short-acting bronchodilator inhalers—commonly known as the “blue” reliever—while neglecting daily preventer medications and objective diagnostic assessments, highlighted the health expert.

“This conventional approach is no longer adequate; it is unsafe and leads to recurrent night-time coughing, missed school and workdays, repeated steroid bursts, emergency visits, and, tragically, preventable deaths,” Dr. Agarwal emphasized. He added that international guidelines have evolved significantly, advocating a paradigm shift in asthma care.

Over the past two decades, clinical evidence supports the use of low-dose inhaled corticosteroid (ICS) combined with formoterol, a fast-acting bronchodilator, as a preferred reliever. Unlike traditional relievers that merely ease symptoms, this combination also targets airway inflammation, offering both immediate relief and disease control, asserted Dr Agarwal.

Known as the SMART (Single Maintenance and Reliever Therapy) or MART (Maintenance and Reliever Therapy) approach, this strategy is now recommended as the first-line reliever for most adolescents and adults. It significantly reduces the risk of severe asthma exacerbations, marking a shift from symptomatic relief to proactive disease management, Dr. Agarwal explained.

Speaking on the nuances of asthma care for different age groups, the pulmonologist emphasized the importance of tailored management strategies for children, pregnant women, and older adults.

Regarding children, he noted that the use of Metered Dose Inhalers (MDI) combined with spacers—along with masks for younger children—remains the most effective delivery method. He stressed the critical role of school action plans and training caregivers to recognize early warning signs such as night-time coughing and increased use of reliever inhalers. “Clinical trials indicate that adding tiotropium can improve lung function in select children and adolescents who continue to experience symptoms despite standard treatment,” he said, advising that specialist consultation is essential in such cases.

Asthma is a chronic lung condition characterized by inflammation and narrowing of the airways, along with excess mucus production, resulting in symptoms such as wheezing, coughing, and shortness of breath, which can vary in intensity. Common triggers include allergens, infections, stress, and physical activity.

On asthma management during pregnancy, Dr. Agarwal underscored that maintaining well-controlled asthma is vital for the health of both mother and child. “Preventer medications should not be discontinued without medical advice,” he cautioned, adding that inhaled therapies are generally continued throughout pregnancy to ensure optimal control.

Addressing older adults, he highlighted the diagnostic challenges, noting that asthma symptoms can often be confused with Chronic Obstructive Pulmonary Disease (COPD) or heart conditions in this age group.

Dr. Agarwal shared his insights on what patients and healthcare providers can expect in asthma management over the coming five years, highlighting promising developments on multiple fronts.

“Upstream targeting of inflammation will gain prominence,” he said. Since the approval of tezepelumab, an anti-TSLP biologic, in 2021—which has demonstrated effectiveness across various asthma phenotypes—research is expanding into other ‘alarmins’ and combination therapies. This broadens the scope for more patients with severe asthma to benefit from biologic treatments, irrespective of their eosinophil counts.

He also emphasized the growing role of home diagnostics and connected care. “Validated devices linked to mobile applications for peak-flow and FeNO monitoring will empower families and clinicians to detect early warning signs, particularly during seasonal exacerbations, while ensuring treatment remains aligned with international guidelines.”

Finally, Dr Agarwal pointed to air-quality integration as a key public health focus. “There is a shift towards simple, actionable public messaging linked to Air Quality Index (AQI) levels—guiding when to time outdoor activities, improve ventilation, and wear masks on high-pollution days. Incorporating these steps into school and workplace plans alongside medical action plans will help reduce asthma triggers and improve overall control.”

On take-home message on asthma management, he said the condition is manageable condition, and with the right treatment plan, individuals can lead full, active lives—studying, working, travelling, playing sports, and sleeping peacefully, Dr. Agarwal said at the same time cautioning against relying solely on the traditional “blue” reliever inhaler (SABA), which is now considered outdated and unsafe. Instead, patients should discuss an anti-inflammatory reliever strategy using low-dose ICS–formoterol with their healthcare providers.

Also, “Recognising early warning signs, such as increasing night-time cough or greater reliance on reliever inhalers, is vital. Using three or more blue inhalers a year is a red flag that signals the need for medical review and adjustment of treatment,” he said.

After any emergency room visit due to asthma, a follow-up consultation within a week is essential to prevent repeat episodes, recommended the doctor.

For those with severe asthma that remains uncontrolled despite basic management, biologic therapies offer promising options, and patients should seek specialist advice, Dr Agarwal added.

Dr. Vijay Kumar Agarwal, Head of Pulmonology and ICU Department at Yatharth Super Speciality Hospital, Faridabad