What is the recommended treatment for a patient with bronchial asthma according to the Global Initiative for Asthma (GINA) guideline 2025?

Bronchial Asthma Management: Patient Guide

What is Asthma?

Asthma is a chronic inflammatory disease of your airways that causes episodes of wheezing, shortness of breath, chest tightness, and coughing. Your airways become swollen and overly sensitive to triggers, leading to temporary narrowing that makes breathing difficult 1.

How Your Doctor Diagnoses Asthma

Your doctor will confirm asthma through breathing tests, not just symptoms alone 2. The diagnosis requires:

• Spirometry testing (breathing test) showing your airways can open up after using an inhaler—specifically, at least 12% improvement AND 200 mL increase in the amount of air you can blow out in one second 2
• Episodic symptoms like wheezing, shortness of breath, or coughing that come and go 2
• Ruling out other conditions that can mimic asthma 2

Important: Never rely on symptoms alone—both patients and doctors frequently underestimate how severe asthma actually is 2.

Understanding Your Asthma Severity

Your asthma severity is determined by how much medication you need to control it, not by how bad your symptoms were before treatment 3. Think of it like this: if you need stronger medications to feel well, you have more severe asthma 3.

Your Treatment Plan

Step 1: Mild Intermittent Asthma

If you have symptoms less than twice per month with no nighttime symptoms:

• Use a low-dose inhaled corticosteroid combined with formoterol (a fast-acting bronchodilator) only when you have symptoms 3
• This approach significantly reduces severe flare-ups compared to using only a rescue inhaler 3

Step 2: Mild Persistent Asthma

If you have symptoms more than twice per month but not daily:

• Preferred option: Continue using low-dose inhaled corticosteroid-formoterol combination only when needed 3
• Alternative: Take a low-dose inhaled corticosteroid daily 2
• Both approaches are equally effective for mild persistent asthma 4

Step 3: Moderate Persistent Asthma

If you have daily symptoms or wake up at night with asthma:

• Take a low-to-medium dose inhaled corticosteroid combined with a long-acting bronchodilator (like formoterol) twice daily 4
• Use the same inhaler for quick relief when symptoms worsen 4
• Alternative options: Medium-dose inhaled corticosteroid alone, or low-dose inhaled corticosteroid plus a leukotriene modifier (like montelukast) 4

Step 4: Severe Persistent Asthma

If symptoms persist despite Step 3 treatment:

• Increase to medium-dose inhaled corticosteroid plus long-acting bronchodilator 4
• Your doctor may add a third medication like a leukotriene modifier 4
• At this point, you should see an asthma specialist 3

Step 5: Very Severe Asthma

If you still have poor control:

• High-dose inhaled corticosteroid plus long-acting bronchodilator 4
• Add a long-acting muscarinic antagonist (LAMA) inhaler for additional benefit 4
• Consider biologic injections (like omalizumab for allergic asthma, or anti-IL-5 medications) 4, 3

Step 6: Refractory Severe Asthma

If maximum inhaled therapy fails:

• Continue high-dose inhaled medications 4
• Add low-dose oral prednisone (≤7.5 mg daily) as a last resort 3
• Biologic therapy is strongly preferred over oral steroids 3

Monitoring Your Asthma Control

Your asthma is "well controlled" if you have ALL of these 4:

• Daytime symptoms ≤2 days per week
• No nighttime awakenings
• Rescue inhaler use ≤2 days per week
• No limitations on your normal activities
• Lung function ≥80% of your personal best 4

Your asthma is "not well controlled" if you have ANY of these 4:

• Daytime symptoms >2 days per week
• Any nighttime awakenings
• Rescue inhaler use >2 days per week
• Any activity limitations
• Lung function 60-80% of personal best 4

Your asthma is "very poorly controlled" if you have 4:

• Symptoms throughout the day
• Nighttime awakenings ≥4 times per week
• Rescue inhaler use several times daily
• Extreme activity limitations
• Lung function <60% of personal best 4

When Your Asthma Flares Up

For mild worsening (increased coughing, mild chest tightness):

• If you use budesonide-formoterol as your regular medication, take 1-2 extra puffs (maximum 8 puffs total per day) 3
• Continue monitoring your symptoms closely 2

For moderate-to-severe flare-ups (significant shortness of breath, difficulty speaking):

• Use your rescue inhaler immediately 5
• Start oral prednisone as directed in your action plan 2
• Seek medical attention if you don't improve within 1-2 hours 5

Go to the emergency room immediately if you have 5:

• Severe shortness of breath at rest
• Difficulty speaking in full sentences
• Bluish lips or fingernails
• Confusion or extreme drowsiness
• No improvement after using your rescue inhaler

Important Safety Information

About Inhaled Corticosteroids

• Long-term use at recommended doses is safe 3
• High doses used for prolonged periods may cause osteoporosis, adrenal gland suppression, or increased pneumonia risk 3
• Never stop these medications suddenly without your doctor's guidance 2

About Long-Acting Bronchodilators

• Never use long-acting bronchodilators (like salmeterol or formoterol) alone—they must always be combined with an inhaled corticosteroid 2
• Using them alone can increase your risk of severe asthma attacks 2

About Rescue Inhalers

• If you're using your rescue inhaler more than twice per week, your asthma is not well controlled 4
• Using more than one canister per month indicates dangerous under-treatment 3

Your Self-Management Responsibilities

You must have a written asthma action plan that includes 2:

• Your daily medications and how to take them
• How to recognize worsening asthma
• What medications to take when symptoms worsen
• When to call your doctor or go to the emergency room

Monitor your asthma at home 2:

• Use a peak flow meter daily if you have moderate-to-severe asthma 4
• Record your symptoms and medication use
• Learn to recognize your early warning signs (like increased coughing or chest tightness) 2

Master your inhaler technique 2:

• Have your doctor or nurse watch you use your inhaler at every visit
• Poor technique means medication doesn't reach your lungs effectively
• Different inhalers require different techniques

Avoiding Asthma Triggers

Identify and control your specific triggers 4, 2:

• Allergens: If you're allergic to dust mites, use allergen-proof mattress and pillow covers as part of a comprehensive plan 4
• Pests: Professional pest control for cockroaches or rodents can significantly help if you're sensitized 4
• Smoking: Avoid all tobacco smoke exposure 3
• Air quality: Stay indoors on high pollution days
• Infections: Get annual flu vaccines and stay up-to-date on COVID-19 vaccination

Important caveat: Single interventions (like air purifiers alone or carpet removal alone) rarely help—you need a comprehensive approach targeting your specific triggers 4.

Follow-Up Care

Schedule visits every 2-4 weeks after starting new treatment, then every 1-3 months once controlled 3. At each visit, your doctor should:

• Review your symptom control and medication use
• Check your inhaler technique 3
• Measure your lung function 2
• Adjust medications based on your control level 4

If your asthma has been well controlled for at least 3 months, your doctor may reduce your medications 4. However, never reduce medications on your own.

When to See a Specialist

You need referral to an asthma specialist if 3:

• You require Step 4 or higher treatment
• You've had a life-threatening asthma attack requiring intubation
• You've been hospitalized or visited the emergency room for asthma in the past year 3
• Your asthma remains uncontrolled despite proper medication use and trigger avoidance

Achieving Asthma Remission

You may achieve "clinical remission" if you have 2, 3:

• At least 1 year with no symptoms
• No asthma flare-ups
• Normal or near-normal lung function
• No need for oral prednisone

Even in remission, continue your maintenance medications unless your doctor specifically tells you to stop 3.

Special Considerations

If You Have Allergies

• Allergy shots (immunotherapy) for dust mites, animal dander, or pollen may reduce your need for asthma medications 4
• Sublingual immunotherapy (tablets under the tongue) for dust mite allergy may help if your lung function is >70% predicted 3

If You're Pregnant

• Controlling your asthma is critical for your baby's health
• Most asthma medications are safe during pregnancy
• Never stop your medications without consulting your doctor

If You Have Frequent Infections

• If you have severe asthma with frequent sinus infections or nasal polyps, biologic medications may help both conditions 3