What are the GINA guidelines for managing asthma exacerbations and long-term control?

GINA Guidelines for Asthma Management and Exacerbations

For long-term asthma control, all adults and adolescents with asthma should receive ICS-containing therapy—either as regular maintenance or as-needed ICS-formoterol—never SABA alone, and for acute exacerbations, early treatment with increased SABA frequency plus oral corticosteroids for severe episodes is the cornerstone of management. 1, 2

Long-Term Asthma Control: The Stepwise Approach

Track 1 (Preferred GINA Strategy)

GINA 2021 introduced a two-track system, with Track 1 using low-dose ICS-formoterol as the reliever medication at all treatment steps: 2

• Steps 1-2 (Mild Asthma): As-needed low-dose ICS-formoterol only, which reduces severe exacerbations by ≥60% compared to SABA alone 3, 2
• Steps 3-5 (Moderate-Severe Asthma): Daily maintenance ICS-formoterol PLUS as-needed ICS-formoterol for symptom relief (MART regimen) 4, 2
• Step 5 additions: Consider add-on long-acting muscarinic antagonists, azithromycin, or biologic therapies for severe asthma 2

Track 2 (Alternative Strategy)

• As-needed SABA across all steps (though not preferred due to risks of SABA-only treatment and overuse) 2
• Step 2: Regular low-dose ICS plus as-needed SABA 2
• Steps 3-5: ICS-LABA combination plus as-needed SABA 2

Critical Treatment Principles

Before stepping up therapy, always verify: 5

• Inhaler technique (incorrect technique is a major cause of treatment failure) 3
• Medication adherence 5
• Environmental trigger exposure 5

Step down therapy only after 3 months of well-controlled asthma 5, 3

Acute Exacerbation Management

Home Management (First-Line Response)

Early treatment at home using a written asthma action plan is the best strategy: 5

• Increase SABA frequency: Every 4-6 hours up to 24 hours (longer with physician consultation) 5
• Add oral corticosteroids if the exacerbation is severe OR the patient has a history of previous severe exacerbations 5
• Do NOT double the ICS dose—this is ineffective 5
• Monitor peak flow if available (particularly useful for patients with difficulty perceiving symptoms or history of severe exacerbations) 5

Severity Classification for Emergency Care

Objective lung function measures (spirometry or PEF) are more reliable than symptoms alone: 5

• Severe exacerbation: <40% predicted FEV1 or PEF—consider adjunctive therapies (magnesium sulfate or heliox) 5
• Discharge goal: ≥70% predicted FEV1 or PEF 5

Emergency Department/Hospital Management

• Oxygen to maintain saturation 5
• Albuterol or levalbuterol (frequent dosing) 5
• Anticholinergics in emergency care (NOT continued in hospital care) 5
• Oral systemic corticosteroids (emphasized over IV unless patient cannot take oral) 5
• Magnesium sulfate or heliox for severe exacerbations unresponsive to initial treatment 5
• Consider initiating ICS at discharge 5

High-Risk Patients Requiring Intensive Monitoring

These patients need special attention and should seek care early during exacerbations: 5, 3

• Previous severe exacerbation requiring intubation or ICU admission 5
• ≥2 hospitalizations or >3 ED visits in the past year 5
• Using >2 canisters of SABA per month 5, 3
• Difficulty perceiving airway obstruction 5
• Low socioeconomic status, illicit drug use, or major psychiatric disease 5

Environmental Control and Trigger Avoidance

Multifaceted environmental control approaches are essential—single interventions alone are generally ineffective: 5, 6

Specific Measures

• Identify sensitizations through skin or in vitro testing for perennial indoor allergens in patients with persistent asthma 5
• Tobacco smoke avoidance for all patients and pregnant women 5
• HVAC maintenance to ensure low indoor humidity and prevent mold growth 6
• Allergen immunotherapy (by trained personnel) for patients with clear relationship between symptoms and allergen exposure at Steps 2-4 5

Environmental modifications can improve asthma control while reducing medication requirements, making this a critical teaching point for children with frequent exacerbations 6

Patient Education and Self-Management

All patients must receive a written asthma action plan that includes: 3

• Daily management instructions (long-term controller medications, environmental control) 5, 3
• Recognition of worsening symptoms (increased cough, wheeze, chest tightness, shortness of breath) 3
• Medication adjustment instructions 5, 3
• Clear criteria for seeking emergency care (severe breathlessness, no improvement despite reliever medication, peak flow <50% of personal best) 3

Education should occur at all points of care: clinics, emergency departments, hospitals, pharmacies, schools, community settings, and patients' homes 5

Monitoring and Follow-Up Schedule

Schedule follow-up visits based on control status: 5

• Every 1-6 weeks while gaining control 5
• Every 1-6 months once control is achieved (depending on treatment step) 5
• Every 3 months if stepping down therapy is anticipated 5

At every visit, assess: 5, 3

• Days per week with symptoms and nighttime awakening 3
• Activity limitations 3
• Number of reliever medication puffs used daily 3
• Spirometry at least every 1-2 years (more frequently for poorly controlled asthma) 5

Common Pitfalls to Avoid

• Never treat asthma with SABA alone—this increases risk of severe exacerbations and death 2
• Never double ICS dose for home exacerbation management—use oral corticosteroids instead 5
• Never implement single environmental modifications—comprehensive multi-trigger reduction is required 6
• Never step up therapy without first checking inhaler technique, adherence, and environmental triggers 5
• Never use LABA as monotherapy—always combine with ICS 5
• Never use anticholinergics beyond emergency care into hospital management 5