Severe asthma is associated with daily symptoms of shortness of breath, disturbed sleep, cough and wheeze, and frequent flare-ups, exacerbations or attacks. During flare-ups people experience sudden, unpredictable and often devastating worsening of symptoms, even when taking high doses of medication. For more information see Prevalence and Burden
Severe Asthma Symptoms
“You wake up and you feel heavy”
Video provided by Professor Lorraine Smith and Dr. Daniela Eassey, University of Sydney
Severe asthma interrupts daily lives, severely limiting activities. Severe asthma symptoms can be debilitating and can interfere with day-to-day living and the ability to work and/or study. Many people with severe asthma also report that their disease limits social and work relationships, career choice, travel and exercise. Symptoms can vary widely within a 24-hour period; which can also make assessment challenging.
“I can’t do certain things….can’t do really heavy work anymore…I get really tired really quickly if I do heavy work”
Video provided by Professor Lorraine Smith and Dr. Daniela Eassey, University of Sydney
Assessment of asthma symptoms is an important part of patient management. Increased symptom frequency and/or severity may warn of an impending exacerbation. There are two commonly used questionnaires that assess asthma control using symptom-experience based items – the Asthma Control Questionnaire (ACQ) and Asthma Control Test (ACT). Both were developed as a measure of asthma control in general asthma but are also frequently used to assess asthma control in people with severe asthma. For more information see Diagnosis – Questionnaires
“Tightness in your chest…huffing and puffing to get in enough air…the air is thick”
Video provided by Professor Lorraine Smith and Dr. Daniela Eassey, University of Sydney
Symptoms associated with asthma treatment
Treatment options for people with severe asthma are increasing, with the approvals of new biologic therapies (e.g. omalizumab/mepolizumab/dupilumab/benralizumab). However, access to targeted therapies depends on accurate asthma diagnosis, referral to a specialist centre, phenotyping, and meeting clinical guidelines for approval. Patient experience of add on therapies (e.g. biologics/macrolides) have demonstrated vast improvements in quality of life, improved symptom management, reduced exacerbations and healthcare utilisation (Clark et al, 2021 & Bever et al. 2024). Biologics ultimately reduce the need for oral corticosteroids, however, the heterogeneity of asthma means the response to biologics varies between patients (Lanario, et al. 2022).
High dose corticosteroids remain a main treatment option to reduce symptoms. Unfortunately, steroids cause toxic and debilitating side effects, especially if taken for long periods. An Australian survey found that 55% of participants reported experiencing side effects of OCS (Jones et al. 2025). Steps are being taken to control the prescribing and usage of oral corticosteroids, by means of stewardship programs and education. The combination of asthma symptoms and symptoms associated with treatment increases disease burden. The often-complex combination of medications required to control severe asthma symptoms is also an ongoing physical reminder of the condition. For more information see Medications – Monoclonal Antibodies.
At lower doses, inhaled steroids have few side effects. The most common include thrush and hoarseness, although this is rare. Patients should be encouraged to thoroughly rinse their mouth after using the asthma inhaler. Using a spacer device with metered dose inhalers can help prevent these side effects.
Side-effects of high doses of corticosteroids include:
- Puffy face and swollen ankles
- Mood swings – mania (euphoria, overexcited, hyperactive) to depression
- Agitation, irritability
- Adrenal insufficiency, causing weight loss and fatigue
- High blood sugar, which can trigger or worsen diabetes
- Increased risk of infections
- Thinning bones (osteoporosis) and fractures
- Thin skin, bruising and slower wound healing
People experiencing the above symptoms are likely to need support to manage symptoms and to ensure adherence is optimised and corticosteroid exposure is minimised, where possible.
