GINA Asthma Management Approach
All adults and adolescents with asthma should receive inhaled corticosteroid (ICS)-containing therapy—either as regular daily treatment or as as-needed ICS-formoterol for symptom relief—to reduce the risk of severe exacerbations and improve outcomes, with short-acting β2-agonist (SABA)-only treatment no longer recommended. 1, 2, 3
Core Treatment Philosophy
The fundamental goal is achieving overall asthma control, which encompasses two domains: day-to-day symptom control and minimizing future risk (preventing exacerbations, avoiding accelerated lung function decline, and eliminating medication side effects). 4 Treatment decisions should focus on the level of asthma control rather than disease severity classification. 5
Stepwise Treatment Algorithm
GINA recommends a 5-step treatment paradigm with two tracks for adults and adolescents: 3
Track 1 (Preferred Approach)
- Step 1 (Mild Intermittent): As-needed low-dose ICS-formoterol only 3
- Step 2 (Mild Persistent): As-needed low-dose ICS-formoterol only 3
- Step 3 (Moderate): Daily maintenance low-dose ICS-formoterol PLUS as-needed ICS-formoterol (MART regimen) 3
- Step 4 (Moderate-Severe): Daily maintenance medium-dose ICS-formoterol PLUS as-needed ICS-formoterol (MART) 3
- Step 5 (Severe): High-dose ICS-formoterol MART, plus consider add-on long-acting muscarinic antagonists, azithromycin, or biologic therapies 3
Track 2 (Alternative Approach)
- Step 1: As-needed SABA only (though not preferred) 3
- Step 2: Regular low-dose ICS plus as-needed SABA 3, 6
- Step 3-5: Regular ICS-long-acting β2-agonist combinations plus as-needed SABA 3
The critical evidence shift: Large trials demonstrate that as-needed ICS-formoterol reduces severe exacerbations by ≥60% in mild asthma compared with SABA alone, with equivalent symptom control and lung function outcomes. 3 This fundamentally changes the approach to even mild disease.
Acute Exacerbation Management
Severity Assessment
Identify severe asthma by: 7, 6
- Inability to complete sentences in one breath
- Respiratory rate >25 breaths/min
- Heart rate >110 beats/min
- Peak expiratory flow (PEF) <50% predicted or personal best
Life-threatening features include: 6
- PEF <33% predicted
- Silent chest, cyanosis, weak respiratory effort
- Bradycardia, hypotension, exhaustion, confusion, or coma
Immediate Treatment
- High-flow oxygen 40-60% in all cases 7
- Nebulized salbutamol 5 mg or terbutaline 10 mg with oxygen as driving gas (or 2 puffs via large-volume spacer repeated 10-20 times if no nebulizer available) 7, 6
- Prednisolone 30-60 mg orally OR hydrocortisone 200 mg IV immediately 7, 6
- Add ipratropium if life-threatening features present 7
Reassessment and Disposition
- Reassess PEF 15-30 minutes after initial bronchodilator therapy 7, 6
- Hospitalize if: PEF remains <50% predicted, oxygen saturation <92%, persistent severe symptoms, or any life-threatening features 6
- Lower threshold for admission: Afternoon/evening attacks, recent nocturnal symptoms, previous severe attacks, or poor social circumstances 7
Follow-Up Requirements
- Primary care review within 24-48 hours for severe exacerbations, within 1 week for others 6
- Respiratory specialist follow-up within 4 weeks 6
- Provide self-management plan and ensure PEF monitoring 7
Children (6-11 Years)
For children, treatment options have been expanded at Steps 3-4, though specific controller medications should be individualized based on age and response. 3 In acute exacerbations: 7
- Salbutamol 5 mg or terbutaline 10 mg nebulized (half doses in very young children)
- Prednisolone 1-2 mg/kg orally (maximum 40 mg)
- MDI with large-volume spacer (face mask for very young) may be as effective as nebulized therapy: give 1 puff every few seconds until improvement (maximum 20 puffs) 7
Critical Safety Considerations
Absolute contraindications: 8, 6
- Never use sedatives in acute asthma—they worsen respiratory depression
- Avoid aminophylline in children at home 7
Antibiotic stewardship: Only administer antibiotics if bacterial infection is clearly documented; yellow sputum alone does not distinguish bacterial from viral etiology. 9, 8
Monitoring and Treatment Adjustment
- Regularly assess using symptom frequency, PEF measurements, and rescue medication use 6
- Step down treatment once control is maintained for 3 months 4
- Step up treatment if asthma remains uncontrolled despite good adherence and technique 4
- Increasing SABA use (>2 days/week or >2 nights/month) indicates inadequate control requiring intensification of anti-inflammatory therapy 6
Diagnostic Confirmation
Before initiating long-term treatment, confirm diagnosis with spirometry or peak expiratory flow measurements. 1 For complicated cases with thrombocytopenia or elevated inflammatory markers, obtain chest radiography to exclude pneumothorax, consolidation, or pulmonary edema. 9