A 16 year old boy presents to A&E with a tight feeling in his chest and a bilateral wheeze. He is a known asthmatic and reports that he usually takes a blue inhaler, he can't remember the name, as and when he needs it. However today, his inhaler did not relieve his symptoms.

What is the single best treatment option for this patient once this acute attack has been treated?
A) Switch to Salbutamol P.R.N inhaler with spacer.
B) Switch to Salmeterol inhaler twice a day.
C) Add Beclometasone inhaler once a day.
D) Add Salmeterol inhaler twice a day.
E) Add oral Prednisolone, 5mg every other day.


The answer is C. The blue inhaler the patient is referring to is most likely salbutamol, this places him on step 1 of the British Thoracic Society Guidelines for asthma management. The criteria for stepping up the ladder are 1) if inhalers need to be used more than once a day 2) if there are nocturnal symptoms 3) if exercise induces symptoms.

Step 2 on the ladder suggests adding a low-dose inhaled steroid, such as beclometasone.

Salmeterol is a long acting beta2-agonist and could be used at step 3 of the ladder.

Oral steroids [such as prednisolone] are the 5th and final step of the ladder.