Bronchial asthma (hereinafter referred to as asthma) is one of the most common chronic respiratory diseases. With the improvement of people’s living standards, the incidence of asthma has increased year by year, and there are at least 20 million asthma patients in China, which has become a public health problem that seriously affects human health and quality of life. Asthma has a long-term and recurrent nature, and there is no cure for it, so there is a saying in the society that “internal asthma is not cured and external ringworm is not cured”. However, a lot of modern medical research has shown that after long-term regular treatment, the number of asthma attacks can be reduced and there are no daytime and nighttime symptoms, thus achieving complete clinical control; the quality of life of most patients can be improved and they can live the same life as healthy people. However, many patients fail to adhere to long-term standardized treatment, which causes great harm. Case information The patient, a 23-year-old female, was admitted to our emergency department with the main reason of “intermittent cough and wheezing for 20 years, aggravated for 2 days”. The patient had cough and wheezing symptoms since she was young (around 1 year old), with 2 to 3 episodes per month, and was diagnosed as “acute bronchitis” by a foreign hospital, which improved after symptomatic treatment. “Three years ago, he was diagnosed with bronchial asthma after a positive bronchodilator test at our outpatient clinic, and was given salmeterol fluticasone powder inhalation (50ug/100ug). treatment. However, the patient refused and thought that long-term hormone inhalation would lead to obesity and affect her body shape and appearance. In the past year, he had frequent episodes of wheezing and other symptoms every day, especially at night, and was treated with salbutamol inhalation on his own. 2 days ago, the patient’s wheezing symptoms continued to be unrelieved, and repeated applications of salbutamol inhalation were ineffective, and his dyspnea gradually worsened, and he was unable to speak and was in a trance. Physical examination: body temperature 37.1℃, respiration 40 times/min, heart rate 150 times/min, blood pressure 140/84mmHg, confused consciousness, seated breathing, sweating profusely, obvious trigeminal sign. Respiratory sounds in both lungs were decreased, and a lot of rales could be heard, and no pleural friction sounds were detected. Arterial blood gas: pH 7.21, PaO2 69mmHg, PaCO2 46mmHg, SaO2 89% (breathing room air). Tracheal intubation and mechanical ventilation were performed immediately. He was transferred to the respiratory care unit (RICU) of our department. During this period, PaCO2 reached a maximum of 117 mmHg and extensive subcutaneous emphysema was observed, which was treated with subcutaneous chest wall incision and venting; ventilator parameters were adjusted to give higher inspiratory pressure and appropriate level of positive end-expiratory pressure (PEEP); intravenous methylprednisolone 160 mg was also administered and other supportive resuscitation measures were given. The patient’s condition gradually improved, the subcutaneous emphysema was absorbed, he became conscious and was successfully discharged from the machine after 3 days. Subsequently, the patient was treated with regular inhalation of salmeterol fluticasone powder inhaler (sulforaphane) and has been followed up in the outpatient clinic with complete control. Analysis This patient was misdiagnosed as bronchitis before the diagnosis of asthma because the symptoms of bronchitis and asthma were similar. However, bronchitis in adolescents is usually caused by pathogenic infections, with an acute course, often accompanied by clinical manifestations such as fever, purulent sputum, and elevated peripheral blood leukocytes; asthma generally has a chronic course with recurrent attacks, and symptoms are mainly wheezing, shortness of breath, chest tightness and cough, and peripheral blood eosinophils can often be elevated. Bronchitis treatment is based on anti-infection therapy, while asthma is based on inhaled glucocorticoids; misdiagnosis of asthma as bronchitis will not only cause abuse of antibiotics, but also lead to long-term lack of standardized treatment for asthma patients, which will seriously affect their quality of life. Medication for asthma is divided into two categories: control medications and relief medications. Control medications are medications that need to be taken daily for a long time. These drugs are mainly used to maintain clinical control of asthma through anti-inflammatory effects, including inhaled glucocorticoids (ICS), long-acting β2 agonists (LABA), leukotriene modulators, slow-release theophylline, etc. Relieving drugs are drugs used on an as-needed basis to relieve asthma symptoms by rapidly relieving bronchospasm, such as β2 agonists (SABA), etc. Standard asthma treatment must be based on the stage, classification and control level of asthma. According to the clinical manifestation of asthma, it can be divided into three periods, such as acute exacerbation, chronic persistence and clinical remission; according to the severity of the disease, it can be divided into four states, such as intermittent state, mild persistence, moderate persistence and moderate persistence; according to its control level, it can be divided into three levels, such as fully controlled, partially controlled and uncontrolled. As a result, long-term standardized treatment regimens for asthma patients are classified into five levels. Level 2 was chosen for patients with previously untreated primary asthma. This patient, who was diagnosed with asthma in our outpatient clinic as a mild persistent state of asthma with significant symptoms, should be directly selected for a Level 3 regimen, such as medium-dose ICS inhalation, low-dose ICS + LABA or leukotriene modulator. The medication is maintained for at least three months after achieving asthma control, and then gradually step-down treatment; if complete control is not achieved, step-up treatment is required. The study results proved that ICS can effectively reduce asthma symptoms, improve quality of life, improve lung function, reduce airway hyperresponsiveness, control airway inflammation, reduce the frequency of asthma attacks and reduce the severity of attacks, and reduce the morbidity and mortality rate. Therefore, ICS is the basic treatment drug regardless of the regimen. Most adult asthma patients can control their asthma well with small doses of inhaled hormones. The inhaled hormone dose required by our asthma patients is smaller than the internationally recommended dose (Table 1). However, regardless of that therapeutic level, SABA is used as needed. Table 1 Daily dose and interchangeability of commonly used inhaled glucocorticoids (μg) Drug Low dose Medium dose High dose Beclomethasone dipropionate 200-500 500-1000 >1000-2000 Budesonide 200-400 400-800 >800-1600 Fluticasone propionate 100-250 250-500 >500-1000 Ciclesonide 80-160 160-320 >320-1280 Modern inhaled drugs often place ICS and LABA in the same device (e.g., sulforaphane quasi-nasal), which is convenient and simple to use and greatly improves efficacy and patient compliance. The molecular structure of LABA has a long side chain, which can maintain the effect of bronchial smooth muscle for more than 12 h. It is suitable for the prevention and treatment of asthma (especially nocturnal asthma and exercise-induced asthma). In recent years, the Global Initiative for the Prevention and Treatment of Asthma (GINA) has recommended the combination of ICS and LABA inhalation for the treatment of asthma because of their synergistic anti-inflammatory and antiasthmatic effects, which can achieve efficacy equivalent to (or better than) that achieved with doubled doses of inhaled hormones, and can increase patient compliance and reduce adverse effects caused by larger doses of inhaled hormones, especially for the long-term treatment of patients with moderate to severe persistent asthma. In fact, ICS is administered through the inhalation process and has a strong local anti-inflammatory effect, which can sometimes cause hoarseness and localized Candida infection in the mouth; systemic adverse effects are rare, and side effects such as obesity, which the patient was worried about, do not occur at all. Unfortunately, however, the patient still refused ICS treatment, which led to an acute major asthma attack. An acute asthma attack is a sudden onset of wheezing, shortness of breath, cough, chest tightness, or a sharp aggravation of existing symptoms, often with dyspnea, characterized by reduced expiratory flow, and often triggered by exposure to allergens, irritants, or respiratory infections. According to the severity of the acute asthma attack, it can be divided into four levels: mild, moderate, severe and critical. The severity varies and the exacerbation can occur within hours or days, or occasionally within minutes, so the condition should be properly evaluated so that timely and effective emergency treatment can be given. In the 1970s, most scholars believed that asthma attacks were caused by bronchospasm, and SABA was once the drug of choice for asthma, but SABA masked airway inflammation while exerting asthma-coping effects. As in the case of this patient, the long-term repeated application of SABA without ICS is very dangerous because it can cause down-regulation of β2-receptors on the cell membrane, resulting in “rapid desensitization” and “drug resistance”, which ultimately leads to an increase in asthma mortality. The patient did not follow the standard asthma treatment protocol, which led to an acute, severe and fatal asthma attack, but the rescue measures were put in place in time to avoid another “Teresa-like tragedy”. It is not too late to mend the fold. We hope that medical workers and asthma patients will take this as a warning and insist on long-term standardized asthma treatment in order to achieve complete control of asthma, improve quality of life and reduce the death rate.