GINA 2022 Guidelines.pdf

Global Initiative For Asthma Guidelines:
Global Strategy For Asthma Management And Prevention - Updated 2022
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Global Strategy For Asthma Management
And Prevention - Updated 2022
Adapted from: 2022 GINA main report [Internet]. Available at: https://ginasthma.org/gina-reports/. Accessed on May 18, 2022.
Asthma is a serious global health problem affecting an estimated 300 million individuals worldwide with
increasing prevalence in many developing countries, rising treatment costs, and a rising burden for patients
and the community. Asthma causes loss in productivity, seriously affects children, disrupts family, and
imposes an unacceptable burden on health care systems. Asthma still results in many deaths worldwide,
including among young people.
The Global Strategy for Asthma Management and Prevention provides a comprehensive and integrated
approach to asthma management that can be adapted for local conditions and for individual patients.
What is known about asthma?
Asthma causes symptoms such as wheezing, shortness of breath, chest tightness and cough that vary over
time in their occurrence, frequency and intensity. Asthma causes bronchoconstriction (airway narrowing),
airway wall thickening, and increased mucus production which results in variable expiratory airflow, i.e.
difficulty breathing air out of the lungs.
There are different types of asthma (also called phenotypes), with different underlying disease processes.
Viral infections, allergens (e.g., house dust mite, pollens, cockroach), tobacco smoke, exercise and stress
can trigger or worsen asthma symptoms. Certain drugs, e.g., beta-blockers, aspirin or other NSAIDs can
also trigger asthma symptoms.
Asthma has two key defining features:
• A history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that
vary over time and in intensity,
• Variable expiratory airflow limitation.

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Patterns of respiratory symptoms that are characteristic of asthma
The following features are typical of asthma and, if present, increase the probability that the patient has
asthma:
• More than one symptom (wheeze, shortness of breath, cough, chest tightness)
• Symptoms often worse at night or in the early morning
• Symptoms vary over time and in intensity
• Symptoms are triggered by viral infections (colds), exercise, allergen exposure, changes in weather,
laughter, or irritants such as car exhaust fumes, smoke or strong smells.
The following features decrease the probability that respiratory symptoms are due to asthma:
• Isolated cough with no other respiratory symptoms
• Chronic production of sputum
• Shortness of breath associated with dizziness, light-headedness or peripheral tingling (paresthesia)
• Chest pain
• Exercise-induced dyspnea with noisy inspiration.
Asthma flare-ups (also called exacerbations or attacks) can be fatal, even in people with apparently mild
asthma. They are more common and more severe when asthma is uncontrolled, and in some high-risk
patients. All patients should have an asthma action plan as asthma flare-ups can occur even in people
taking asthma treatment. Treatment with inhaled corticosteroid (ICS)-containing medications markedly
reduces the frequency and severity of asthma symptoms and markedly reduces the risk of flare-ups or
dying of asthma.
Asthma treatment should be customized to the individual patient, taking into account their level of symptom
control, their risk factors for exacerbations, phenotypic characteristics, and preferences, as well as the
effectiveness of available medications, their safety, and their cost to the payer or patient.

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Making the diagnosis of asthma
Asthmaisadiseasewithmanyvariations(phenotypes),usuallycharacterizedbychronicairwayinflammation.
Asthma has two key defining features, viz., a history of respiratory symptoms such as wheeze, shortness
of breath, chest tightness and cough that vary over time and in intensity, and variable expiratory airflow
limitation.
A flowchart for making the diagnosis in clinical practice is shown in Figure 1 with the specific criteria for
diagnosing asthma in Table 1
Patient with respiratory
symptoms (Box 1-2)
Are the symptoms typical of asthma?
Empiric initial treatment
(See Boxes 3-4, A-D)
Review response
Diagnostic testing within
1-3 months (Box 1-4)
Further history and tests for
alternative diagnoses (Box 1-5)
Alternative diagnosis
confirmed?
Treat for alternative diagnosis
Arrange other tests (Box 1-2)
Confirms asthma diagnosis?
See Boxes 1-3 and 1-4 for
diagnostic steps in patients
on controller treatment?
Consider trial of treatment for
most likely diagnosis, or refer
for further investigations
Detailed history/examination for asthma
History/examination supports
asthma diagnosis?
Is patient already taking asthma
controller treatment?
Perform spirometry/PEF with
reversibility test (Box 1-2)
Results support asthma diagnosis?
Treat for ASTHMA
(Boxes 3-4, A-D)
YES
NO
NO
NO
NO
NO
YES
YES
YES
YES
Clinical urgency, and
other diagnoses unlikely
YES
Figure 1: Diagnostic flow-chart for asthma in clinical practice

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The diagnosis of asthma should be confirmed, and the evidence documented in the patient’s medical
record, preferably before starting controller treatment. Confirming the diagnosis of asthma is more difficult
after treatment has been started.
Table 1: Symptoms used in making the diagnosis of asthma
1. A history of variable respiratory symptoms
Typical symptoms are wheeze, shortness of breath, chest tightness, cough:
• People with asthma generally have more than one of these symptoms,
• The symptoms occur variably over time and vary in intensity
• The symptoms often occur or are worse at night or on waking
• Symptoms are often triggered by exercise, laughter, allergens or cold air
• Symptoms often occur with or worsen with viral infections.
2. Evidence of variable expiratory airflow limitation
• At least once during the diagnostic process (e.g. when FEV1 is low), document that the FEV1/FVC ratio
is below the lower limit of normal†.
• Document that variation in expiratory lung function is greater than in healthy people. For example,
excess variability is recorded if:
o FEV1 increases after inhaling a bronchodilator by >200 mL and >12% of the pre-bronchodilator value
(or in children, increases from the pre-bronchodilator value by >12% of the predicted value). This is
called significant bronchodilator responsiveness or reversibility.
o Average daily diurnal PEF variability is >10% (in children, >13%) o FEV1 increases by more than
12% and 200 mL from baseline (in children, by >12% of the predicted value) after 4 weeks of anti-
inflammatory treatment (outside respiratory infections).
• The greater the variation, or the more times excess variation is seen, the more confident you can be of
the diagnosis of asthma.
• Testing may need to be repeated during symptoms, in the early morning, or after withholding
bronchodilator medications.
• Significant bronchodilator reversibility may be absent during severe exacerbations or viral infections. If
significant bronchodilator reversibility is not present when it is first tested, the next step depends on the
clinical urgency and the availability of other tests
FEV1, forced expiratory volume; FVC, forced vital capacity; PEF, peak expiratory flow

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How to confirm the diagnosis in patients taking controller treatment
Physical examination in people with asthma is often normal, but the most frequent
finding is wheezing on auscultation, especially on forced
For many patients (25–35%) with a diagnosis of asthma in primary care, the diagnosis cannot be confirmed.
• If the basis of the diagnosis has not already been documented, it should be confirmed with objective
testing.
• If standard criteria for asthma (Table 2) are not met, consider other investigations. For e.g., if lung
function is normal, repeat reversibility testing when the patient is symptomatic, or after withholding
SABA for >4 hours, twice-daily ICS-LABAs for >24 hours, and once-daily ICS+LABAs for >36 hours
• If the patient has frequent symptoms, consider a trial of step-up in controller treatment and repeat lung
function testing after 3 months.
• If the patient has few symptoms, consider stepping down controller treatment; ensure the patient has a
written asthma action plan, monitor them carefully, and repeat lung function testing.
Table 2: Steps for confirming the diagnosis of asthma in a
patient already taking controller treatment
Current status Steps to confirm the diagnosis of asthma
Variable respiratory
symptoms and variable
airflow limitation
• Diagnosis of asthma is confirmed.
• Assess the level of asthma control and review controller treatment
Variable respiratory
symptoms but no
variable airflow
limitation
• Repeat spirometry after withholding BD (4 hrs for SABA, 24 hrs for twice-
daily ICS+LABA, 36hrs for once-daily ICS+LABA) or during symptoms.
• Check between-visit variability of baseline FEV1, and bronchodilator
responsiveness.
• If still normal, consider alternative diagnoses
o If FEV1 is >70% predicted: consider a bronchial provocation test or
repeating BD responsiveness.
o If negative, consider stepping down controller treatment and reassess in
2–4 weeks
o If FEV1 is <70% predicted: consider stepping up controller treatment for 3
months, then reassess symptoms and lung function.
o If no response, resume previous treatment and refer patient for diagnosis
and investigation.

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Few respiratory
symptoms, normal
lung function, and
no variable airflow
limitation
• Repeat BD responsiveness test again after withholding BD as above or
during symptoms.
• If normal, consider alternative diagnoses
• Consider stepping down controller treatment
o If symptoms emerge and lung function falls: asthma is confirmed. Step up
controller treatment to previous lowest effective dose.
o If no change in symptoms or lung function at lowest controller step:
consider ceasing controller, and monitor patient closely for at least 12
months
Persistent shortness of
breath and persistent
airflow limitation
• Consider stepping up controller treatment for 3 months then reassess
symptoms and lung function.
• If no response, resume previous treatment and refer patient for diagnosis
and investigation.
• Consider asthma–COPD overlap
Diagnosing asthma in other contexts
Category Diagnosis
Patients presenting
with persistent non-
productive cough as
the only respiratory
symptom
• Diagnoses to be considered are chronic upper airway cough syndrome
(often called ‘postnasal drip’), cough induced by angiotensin converting
enzyme (ACE) inhibitors, gastroesophageal reflux, chronic sinusitis, and
inducible laryngeal obstruction
• Cough-variant asthma must be distinguished from eosinophilic bronchitis in
which patients have cough and sputum eosinophilia but normal spirometry
and airway responsiveness
Occupational asthma
and work-aggravated
asthma
• Approximately 5–20% of new cases of adult-onset asthma are due to
occupational exposure
• Every patient with adult-onset asthma should be asked about occupational
exposures, and whether their asthma is better when they are away from
work.
• It is important to confirm the diagnosis objectively and to eliminate
exposure as quickly as possible.
• Frequent PEF monitoring at and away from work frequently helps confirm
the diagnosis.
Athletes
• Lung function tests, usually with bronchial provocation testing should be
used to confirm the diagnosis of asthma in athletes
• It is important to exclude conditions that may either mimic or be associated
with asthma, such as rhinitis, laryngeal disorders (e.g., inducible laryngeal
obstruction36), dysfunctional breathing, cardiac conditions and over-
training.

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Pregnant women
• It is essential to ask all pregnant women and those planning pregnancy
about asthma, and advise them about the importance of taking asthma
controller treatment for the health of both mother and baby.
• For objective confirmation of the diagnosis, it would not be advisable to
carry out a bronchial provocation test or to step down controller treatment
until after delivery.
The elderly
• In the elderly, asthma may be under-diagnosed due to poor perception, an
assumption that dyspnea is normal in old age, lack of fitness, or reduced
activity.
• Presence of multimorbidity complicated diagnosis in these patients.
• On the other hand, it can be over-diagnosed through confusion with
shortness of breath due to left ventricular failure or ischemic heart disease.
• A careful history and physical examination, combined with an
electrocardiogram and chest X-ray, will assist in the diagnosis.
• Measurement of plasma brain natriuretic polypeptide (BNP) and assessment
of cardiac function with echocardiography may also be helpful.
• COPD or asthma-COPD overlap should be considered in the elderly with
history of smoking or biomass fuel exposure.
Smokers and
ex-smokers
• It can be challenging to distinguish between asthma and COPD in clinical
practice, especially in older patients and smokers and ex-smokers, and the
two conditions can overlap (asthma-COPD overlap).
• The history and pattern of symptoms and previous records can help
differentiate these patients from those who have had long-term asthma and
have developed persistent airflow limitations.
• Patients with asthma-COPD overlap have worse outcomes than those with
asthma or COPD alone, so any uncertainty in the diagnosis should prompt
early referral for specialized investigation and treatment recommendations.
Obese patients
• Obesity-related respiratory symptoms can be mistaken for asthma.
• Obese patients with exertional dyspnea should have their asthma diagnosis
confirmed with objective measurement of variable expiratory airflow
limitation.
Low- and middle-
income countries
• Lung function testing is often difficult to come by, and even when it is, it is
frequently underutilized.
• Other endemic respiratory diseases may be included in the differential
diagnosis of asthma.
• GINA advises against making a diagnosis solely based on syndromic clinical
patterns.
• PEF can confirm the presence of variable expiratory airflow limitation
(including reversible obstruction) when spirometry is not available.
• Several strategies have been developed to improve respiratory disease
management in LMICs, including a structured algorithmic approach to
patients presenting with respiratory symptoms.

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Assessing a patient with asthma
Take every opportunity to assess patients with asthma, particularly when they are symptomatic or after a
recent exacerbation, but also when they ask for a prescription refill. In addition, schedule a routine review
at least once a year.
1. How to assess a patient with asthma
Asthma control – assess both symptom control and risk factors
• Assess symptom control over the last 4 weeks (next table).
• Identify any modifiable risk factors for poor outcomes (next table).
• Measure lung function before starting treatment, 3–6 months later, and then periodically, e.g. at least
yearly in most patients
2. Are there any co-morbidities?
• These include rhinitis, chronic rhinosinusitis, gastroesophageal reflux (GERD), obesity, obstructive
sleep apnea, depression and anxiety.
• Comorbidities should be identified as they may contribute to respiratory symptoms, flare-ups and poor
quality of life. Their treatment may complicate asthma management.
3. Treatment issues
• Record the patient’s treatment. Ask about side-effects
• Watch the patient using their inhaler, to check their technique
• Have an open empathic discussion about adherence
• Check that the patient has a written asthma action plan
• Ask the patient about their goals and preferences for asthma treatment
How to assess asthma control
Asthma control means the extent to which the effects of asthma can be seen in the patient, or have been
reduced or removed by treatment. Asthma control has two domains: symptom control and risk factors for
future poor outcomes, particularly flare-ups (exacerbations) (Figure 2). Poor symptom control is a burden
to patients and a risk factor for flare-ups.

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A. Asthma symptom control Level of asthma symptom control
In the past 4 weeks, has the patient had:
Well
controlled
Partly
controlled
Uncontrolled
• Daytime asthma symptoms more than twice/week? Yes No
• Any night waking due to asthma? Yes No
• SABA reliever for symptoms more than twice/week?* Yes No
• Any activity limitation due to asthma? Yes No
None of
these
1-2
of these
3-4
of these
B. Risk factors for poor asthma outcomes
Assess risk factors at diagnosis and periodically, particularly for patients experiencing exacerbations.
Measure FEV1
at start of treatment, after 3–6 months of controller treatment to record the patient’s personal best
lung function, then periodically for ongoing risk assessment.
Having uncontrolled asthma symptoms is an important risk factor for
exacerbations.
Additional potentially modifiable risk factors for flare-ups (exacerbations), even in
patients with few symptoms† include:
• Medications: high SABA use (≥ 3 x 200-dose canisters/year associated with
increased risk of exacerbations; increased mortality particularly if ≥1 canister
per month); inadequate ICS: not prescribed ICS; poor adherence; incorrect
inhaler technique
• Other medical conditions: obesity; chronic rhinosinusitis; GERD; confirmed
food allergy; pregnancy95
• Exposures: smoking; e-cigarettes; allergen exposure if sensitized; air pollution
• Context: major psychological or socioeconomic problems
• Lung function: low FEV1, especially <60% predicted; high BD responsiveness
• Type 2 inflammatory markers: higher blood eosinophils; elevated FeNO (in
adults with allergic asthma taking ICS)
Other major independent risk factors for flare-ups (exacerbations)
• Ever intubated or in intensive care unit for asthma
• ≥1 severe exacerbation in last 12 months
Having any of
these risk factors
increases the
patient’s risk of
exacerbations
even if they
have few asthma
symptoms
Risk factors for developing persistent airflow limitation
• History: preterm birth, low birth weight and greater infant weight gain; chronic mucus hypersecretion
• Medications: lack of ICS treatment in patients who had a severe exacerbation
• Exposures: tobacco smoke; noxious chemicals; occupational exposures
• Investigations: low initial FEV1; sputum or blood eosinophilia
Risk factors for medication side-effects
• Systemic: frequent OCS; long-term, high dose and/or potent ICS; also taking P450 inhibitors
• Local: high dose or potent ICS; poor inhaler technique
Figure 2: GINA assessment of asthma control in adults, adolescents and children 6–11 years
BD: bronchodilator; FEV1: forced expiratory volume in 1 second; ICS: inhaled corticosteroid; OCS: oral corticosteroid; P450 inhibitors:
cytochrome P450 inhibitors such as ritonavir, ketoconazole, itraconazole; SABA: short-acting beta2-agonist. *Based on SABA (as-needed ICS-
formoterol reliever not included); excludes reliever taken before exercise. For children 6–11 years, also refer to Box 2-3, p.37. See Box 3-8, p.74
for specific risk reduction strategies. †‘Independent’ risk factors are those that are significant after adjustment for the level of symptom control.
Risk factors are factors that increase the patient’s future risk of having exacerbations (flare-ups), loss of
lung function, or medication side-effects.

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Frequency of reliever user
The frequency of SABA reliever use (< 2 or ≥ 2 days/week) has been included in the composite symptom
control assessment. This distinction was made because if SABA was used >2 times per week, the
patient needed to start controller therapy or increase the dose. In addition, higher average SABA use
over a year is linked to a higher risk of severe exacerbations, and increasing as-needed SABA use is
linked to a higher risk of severe exacerbation in the days or weeks following.
However, if a patient prescribed as-needed ICS-formoterol as a reliever uses it on average > 2 days/
week, it is already providing additional controller therapy, and dose escalation may not be necessary.
When the reliever is SABA, or if the patient is using SABA alone, increasing the use of as-needed ICS-
formoterol is associated with a significantly lower risk of severe exacerbation in the following days or
weeks.
As a result, the composite assessment of symptom control excludes using an ICS-formoterol reliever
divided categorically as ≤ 2 versus > 2 days/week. However, when the patient’s maintenance controller
dose is reviewed, the patient’s average frequency of as-needed ICS-formoterol use over the previous 4
weeks should be assessed and considered.
Assessing Asthma Severity
The currently accepted definition of asthma severity is based on ‘difficulty to treat.
According to the current definition of asthma severity, which was recommended by an ATS/ERS Task
Force and is included in most asthma guidelines, severity should be determined retrospectively from
the level of treatment required to control the patient’s symptoms and exacerbations, i.e., after at least
several months of treatment. Hence:
• Severe asthma is defined as asthma that is uncontrolled despite optimal treatment with high dose
ICS-LABA or that requires high dose ICS-LABA to avoid becoming uncontrolled.
• Moderate asthma is that which is well controlled with Step 3 or Step 4 treatment, such as low or
medium dose ICS-LABA in either treatment track.
• Mild asthma is that which is well controlled with as-needed ICS-formoterol or low-dose ICS plus as-
needed SABA
Severe asthma is defined in a widely accepted way and is helpful in clinical practice. The utility and
relevance of the corresponding definition of mild asthma, on the other hand, are far less clear. Patients
and clinicians frequently believe that “mild asthma” means there is no risk and no need for controller
treatment, but people with infrequent symptoms account for up to 30% of asthma deaths.

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How to investigate uncontrolled asthma
Currently, asthma severity is assessed retrospectively from the level of treatment required to control
symptoms and exacerbations. Mild asthma is asthma that can be controlled with reliever alone or low dose
ICS. Severe asthma is asthma that requires high dose ICS-LABA. It may appear similar to asthma that is
uncontrolled due to lack of treatment (Figure 3).
Watch patient using their
inhaler
Discuss adherence and
barriers to use
Confirm the diagnosis of
asthma
Consider treatment
step-up
If possible remove
potential risk factors
Assess and manage
comorbidities
Refer to a specialist or
severe asthma clinic
• Watch patient use their inhaler(s), check against inhaler checklist. Show correct method,
and recheck, up to 3 times. Re-check each visit
• Have empathic discussion to identify poor adherence, e.g. “Many patients don’t use their
inhaler as prescribed. In the last 4 weeks, how many days a week have you taken it?” (0
days, 1, 2, 3 etc) and/or: “Do you find it easier to remember your inhaler in the morning
or the evening? Ask about beliefs, cost of medications, and refill frequency.
• If no evidence of variable airflow limitation on spirometry or other testing (Box 1-2),
consider halving ICS dose and repeating lung function after 2-3 weeks (Box 1-5); check
patient has action plan. Consider referring for challenge test.
• Consider step up to next treatment level or alternative option on present level
(Box 3-5A).
• Use shared decision-making, and balance potential benefits and risks
• Check for risk factors or inducers such as smoking, beta-blockers or NSAIDs, or
occupational or domestic ailergen exposure (Box 2-2), and address as possible
(Box 3-8).
• Check for and manage comorbidities (e.g. rhinitis, obesity. GERD, obstructive sleep
apnea, depression/anxiety ) that may contribute to symptoms
• If asthma still uncontrolled after 3-6 months on high dose ICS-LABA, or with ongoing risk
factors, refer to a specialist or severe asthma clinic (Box 3-14).
• Refer earlier than 6 months if asthma very severe or difficult to manage, or if doubts
about diagnosis.
Figure 3: Steps to investigate uncontrolled asthma in primary care

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Management of asthma
The long-term goals of asthma management are to achieve good symptom control, and to minimise future
risk of asthma-related mortality, exacerbations, persistent airflow limitation and side-effects of treatment.
The patient’s own goals regarding their asthma and its treatment should also be identified.
Treatment to prevent asthma exacerbations and control symptoms includes:
• Medications
o GINA now recommends that every adult and adolescent with asthma should receive ICS-containing
controller medication to reduce their risk of serious exacerbations, even patients with infrequent
symptoms.
o Every patient with asthma should have a reliever inhaler for as-needed use, either low dose ICS-
formoterol or SABA.
Every patient should also be trained in essential skills
and guided asthma self-management, including:
• Asthma information
• Inhaler skils
• Adherence
• Written asthma action plan
• Self-monitoring of symptoms and/or peak flow
• Regular medical review
The patient’s response should be evaluated
whenever treatment is changed.
Assess symptom control, exacerbations, side-effects,
lung function and patient (and parent, for children with
asthma) satisfaction.
o ICS-formoterol is the preferred reliever,
because it reduces the risk of severe
exacerbations compared with treatment
options in which the reliever is SABA.
o However, ICS-formoterol should not be
used as the reliever by patients who are
taking a different maintenance ICS-LABA;
for these patients, the appropriate reliever
is SABA.
• Treating modifiable risk factors and
comorbidities
• Using non-pharmacological therapies
and strategies as appropriate
The Patient-Health Care Provider Partnership
A partnership between the person with asthma (or the parent/carer) and health care providers is vital for
effective asthma management.
Management strategy should enable the patient to gain the knowledge, confidence and skills to assume a
major role in their treatment journey to reduce reduces asthma morbidity in both adults and children.
The foundation of good outcomes is good communication by health care providers.Improved communication
can lead to increased patient satisfaction, better health outcomes, improved treatment compliance and
reduced use of health care resources without lengthening consultation times (Table 3).

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Table 3: Communication strategies for health care providers
Key strategies to facilitate good communication
• A congenial demeanor (friendliness, humor and attentiveness)
• Allowing the patient to express their goals, beliefs and concerns
• Empathy, reassurance, and prompt handling of any concerns
• Giving encouragement and praise
• Giving appropriate (personalized) information
• Providing feedback and review
How to reduce the impact of low health literacy
• Order information from most to least important.
• Speak slowly and use simple words (avoid medical language, if possible).
• Simplify numeric concepts (e.g. use numbers instead of percentages).
• Frame instructions effectively (use illustrative anecdotes, drawings, pictures, table or graphs).
• Confirm understanding by using the ‘teach-back’ method (ask patients to repeat instructions).
• Ask a second person (e.g. nurse, family member) to repeat the main messages.
• Pay attention to non-verbal communication by the patient.
• Make patients feel comfortable about asking questions.
The Asthma Management Cycle To Minimize Risk And Control Symptoms
Asthma control has two domains: symptom control and risk reduction. In control-based asthma
management, pharmacological and non-pharmacological treatment is adjusted in a continuous cycle
involving assessment, treatment and review by appropriately trained personnel.
Asthma management involves a continuous cycle to assess, adjust treatment and review response. In
control-based asthma management, pharmacological and non-pharmacological treatment is adjusted in a
continuous cycle that involves assessment, treatment and review (Figure 4).
Confirmation of diagnosis if necessary
Symptom control & modifiable risk factors
(including lung function) Comorbidities
Inhaler technique & adherence Patient
(and parent) preferences and goals
Symptoms Exacerbations Side-
effects Lung function Patient (and
parent) satisfaction
Treatmentofmodifiableriskfactorsand
comorbidities Non-pharmacological
strategies Asthma medications
(adjust down/up/ between tracks)
Education & skills training
ADJUST
R
E
V
I
EW A
S
S
E
S
S
Figure 4:The control-based asthma management cycle

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GINA recommendations for mild asthma
• All adults and adolescents with asthma should receive ICS-containing controller treatment to reduce
their risk of serious exacerbations and to control symptoms.
• For adults and adolescents, the treatment options for mild asthma are:
o as-needed low dose ICS-formoterol (preferred), or
o regular low dose ICS, plus as-needed SABA
Starting asthma treatment
For the best outcomes, ICS-containing treatment should be initiated as soon as possible after the diagnosis
of asthma is made, because:
• Patients with even mild asthma can have severe exacerbations
• Low dose ICS markedly reduces asthma hospitalizations and death
• Low dose ICS is very effective in preventing severe exacerbations, reducing symptoms, improving lung
function, and preventing exercise-induced bronchoconstriction, even in patients with mild asthma
• Early treatment with low dose ICS is associated with better lung function than if symptoms have been
present for more than 2–4 years
• Patients not taking ICS who experience a severe exacerbation have lower long-term lung function than
those who have started ICS
• In occupational asthma, early removal from exposure and early treatment increase the probability of
recovery
• Patients who begin treatment with SABA alone are more likely to regard it as their primary
asthma treatment, which increases the risk of poor adherence when daily ICS is prescribed
later.
• For most adults or adolescents with asthma, treatment can be started at Step 2 with either as-
needed low dose ICS-formoterol (preferred), or regular daily low dose ICS with as-needed SABA
(Figures 5 and 6)
• Most patients with asthma do not need higher doses of ICS, because at a group level, most of the
benefit (including prevention of exacerbations) is obtained at low doses
• Consider starting at Step 3 (e.g., maintenance and reliever therapy with low dose ICS-formoterol) if,
at initial presentation, the patient has troublesome asthma symptoms on most days; or is waking from
asthma ≥ once/week.
• If the patient has severely uncontrolled asthma at initial asthma presentation, or the initial presentation
is during an acute exacerbation, start regular controller treatment at Step 4 (e.g., medium dose ICS-
formoterol maintenance and reliever therapy); a short course of OCS may also be needed.
• Consider stepping down after asthma has been well-controlled for 3 months.
• However, in adults and adolescents, ICS should not be completely stopped.

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Asthma treatment tracks for adults/adolescents
The options for ongoing treatment for adults and adolescents have been clarified in the main treatment
figure (Figures 5 and 6) by showing two treatment ‘tracks’
.
The key difference between the tracks is the medication that is used for symptom relief: as-needed low
dose ICS-formoterol in Track 1 (preferred), and as-needed SABA in Track 2.
Track 1:The reliever is as-needed low dose ICS-formoterol
This is the preferred approach recommended by GINA for adults and adolescents.
• Using low dose ICS-formoterol as reliever (sometimes called ‘anti-inflammatory reliever’ or AIR) reduces
the risk of severe exacerbations compared with regimens with SABA as reliever (Table 4, with similar
symptom control.
• With this approach:
o When a patient at any treatment step has asthma symptoms, they use low dose ICS-formoterol in a
single inhaler for symptom relief and to provide their anti-inflammatory therapy.
o In Steps 3–5, patients also take ICS-formoterol as their regular daily treatment. This is called
‘maintenance and reliever therapy’ (MART).
o ICS-formoterol should not be used as the reliever by patients taking any other ICS-LABA.
Track 2:The reliever is as-needed SABA
This is an alternative approach if Track 1 is not possible, or if a patient’s asthma is stable with good
adherence and no exacerbations on their current therapy. However (Table 4)
• In Step 1, the patient takes a SABA and a low dose ICS together for symptom relief when symptoms
occur, either in a combination inhaler, or with the ICS taken right after the SABA
• In Steps 2–5, a SABA (alone) is used for symptom relief, and the patient takes ICS-containing controller
medication regularly every day.
• Before prescribing a regimen with SABA reliever, consider whether the patient is likely to be adherent
with their ICS-containing controller therapy, as otherwise they will be at higher risk of exacerbations.
• During ongoing treatment, treatment can be stepped up or down along one track, using the same
reliever at each step, or it can be switched between tracks, according to the individual patient’s needs.
• Before stepping up, check for common problems such as incorrect inhaler technique, poor adherence,
and environmental exposures, and confirm that the symptoms are due to asthma

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Table 4: Initial asthma treatment - recommended options for adults and adolescents
Presenting symptoms
Preferred INITIAL treatment
(Track 1)
Alternative INITIAL treatment
(Track 2)
Infrequent asthma symptoms,
e.g. less than twice a month and
no risk factors for exacerbations,
including no exacerbations in the
last 12 months
• As-needed low dose ICS-
formoterol
• Low dose ICS taken
whenever SABA is taken,
in combination or separate
inhalers
Asthma symptoms or need for
reliever twice a month or more
• As-needed low dose ICS-
formoterol
• Low dose ICS with as-needed
SABA
• Before choosing this option
Consider likely adherence
with daily ICS
Troublesome asthma symptoms
most days (e.g. 4–5 days/week);
or waking due to asthma once a
week or more, especially if any risk
factors exist
• Low dose ICS-formoterol
maintenance and reliever
therapy
• Low dose ICS-LABA with as-
needed SABA, OR Medium
dose ICS with as-needed
SABA
• Consider likely adherence
with daily controller
Initial asthma presentation is with
severely uncontrolled asthma, or
with an acute exacerbation
• Medium dose ICS-formoterol
maintenance and reliever
therapy
• A short course of oral
corticosteroids may also be
needed
• Medium or high dose ICS-
LABA with as needed SABA.
• Consider likely adherence
with daily controller.
• A short course of oral
corticosteroids may also be
needed
Before starting initial controller treatment
• Record evidence for the diagnosis of asthma
• Record the patient’s level of symptom control and risk factors, including lung function
• Consider factors influencing choice between available treatment options, including likely adherence
with daily controller, particularly if the reliever is SABA.
• Ensure that the patient can use the inhaler correctly.
• Schedule an appointment for a follow-up visit.
After starting initial controller treatment
• Review patient’s response after 2–3 months, or earlier depending on clinical urgency.
• Check adherence and inhaler technique frequently.
• Step down treatment once good control has been maintained for 3 months

17
Adults & adolescents
12+ years
Personalized asthma management
Assess, Adjust, Review
for individual patient needs
Treatment of modifiable risk factors and
strategies Asthma medications (adjust
down/up/ between tracks) Education
& skills training ADJUST
R
E
V
I
EW A
S
S
E
S
S
Add-on LAMA
Refer for phenotype
assessment. Consider
high dose maintenance
ICS-formoterol, ±
anti-IgE, anti-IL5/5R,
anti-IL4R, anti-TSLP
Add-on LAMA
Refer for assessment
of phenotype. Consider
high dose maintenance
ICS-LABA, ± anti-IgE,
anti-IL5/5R, anti-IL4R,
anti-TSLP
Figure 5:The GINA asthma treatment strategy – adults and adolescents
ICS: inhaled corticosteroid; LABA: long-acting beta2-agonist; LAMA: long-acting muscarinic antagonist; LTRA: leukotriene recep-
tor antagonist; OCS: oral corticosteroid; SABA: short-acting beta2-agonist

18
Starting Treatment
in adults and adolescents with a diagnosis of asthma
Track 1 is preferred if the patient is likely to be poorly adherent with daily controller ICS-containing
therapy is recommended even if symptoms are infrequent, as it reduces the risk of severe exacerbations
and need for OCS.
Add-on LAMA
Refer for assessment of
phenotype. Consider high
dose maintenance ICS-LA-
BA, ± anti-IgE, anti-IL5/5R,
STEP 5
STEP 5
Add-on LAMA
Refer for assessment of
phenotype. Consider high
dose maintenance ICS-LA-
BA, ± anti-IgE, anti-IL5/5R,
Figure 6: Initial treatment: adult or adolescents with a diagnosis of asthma
ICS: inhaled corticosteroid; SABA: short-acting beta2-agonist

19
Initial asthma treatment for children aged 6–11 years
Table 5: Initial asthma treatment - recommended options for children aged 6–11 years
Presenting symptoms Preferred INITIAL treatment
Infrequent asthma
symptoms,
e.g. less than twice a
month and no risk factors
for exacerbations
• As-needed SABA (Figures 7 and 8)
• Other options include taking ICS whenever SABA is taken, in
combination or separate inhalers.
Asthma symptoms or
need for reliever twice a
month or more but less
than daily
• Low dose ICS with as-needed SABA, or
• Other options include daily LTRA (less effective than ICS), or taking ICS
whenever SABA is taken in combination or separate inhalers
• Consider likely adherence with controller if reliever is SABA.
Troublesome asthma
symptoms mostdays (e.g.
4–5 days/week); or waking
due to asthma once a
week or more, especially if
any risk factors exist
• Low dose ICS-LABA with as needed SABA, OR
• Medium dose ICS with as-needed SABA, OR
• Very low dose ICS-formoterol maintenance and reliever
• Other options include low dose ICS with daily LTRA, with as needed
SABA.
Initial asthma
presentation is with
severely uncontrolled
asthma, or with an acute
exacerbation
• Start regular controller treatment with medium dose ICS-LABA with
as-needed SABA or low dose ICS-formoterol maintenance and reliever
(MART).
• A short course of OCS may also be needed.
Before starting initial controller treatment
• Record evidence for the diagnosis of asthma, if possible
• Record the child’s level of symptom control and risk factors, including lung function
• Consider factors influencing choice between available treatment options
• Ensure that the child can use the inhaler correctly
• Schedule an appointment for a follow-up visit.
After starting initial controller treatment
• Review child’s response after 2–3 months, or earlier depending on clinical urgency
• Step down treatment once good control has been maintained for 3 months

20
Children 6-11 years
Personalized asthma management:
Assess, Adjust, Review
Asthma medication options:
Adjust treatment up and down for
individual child’s needs
Treatment of modifiable risk factors and
strategies Asthma medications (adjust
down/up/ between tracks) Education
& skills training ADJUST
R
E
V
I
EW A
S
S
E
S
S
Refer for pheno-
typic assessment
± higher dose
ICS-LABA or add-
on therapy, e.g.
anti-IgE, anti-IL4R
Add-on anti-IL5,
or, as last resort,
consider add-on low
dose OCS, but con-
sider side-effects
Figure 7: The GINA asthma treatment strategy – children 6–11 years
ICS: inhaled corticosteroid; LABA: long-acting beta2-agonist; LTRA: leukotriene receptor antagonist; OCS: oral corticosteroid;
SABA: short-acting beta2-agonist

21
Starting Treatment
Children 6-11 years with a diagnosis of asthma
Figure 8: Initial treatment: children 6–11 years with a diagnosis of asthma
ICS: inhaled corticosteroid; LABA: long-acting beta2-agonist; LTRA: leukotriene receptor antagonist; OCS: oral corticosteroid;
SABA: short-acting beta2-agonist
Low dose ICS provides most of the clinical benefit for most patients.
• However, ICS responsiveness varies between patients, so some patients may need medium dose ICS
if asthma is uncontrolled despite good adherence and correct inhaler technique with low dose ICS.
• High dose ICS is needed by very few patients, and its long-term use is associated with an increased risk
of local and systemic side-effects

22
Table 6: Low, medium and high daily doses of inhaled corticosteroids
Adults and adolescents
Inhaled corticosteroid
Total daily ICS dose (mcg)
Low Medium High
BDP (PMDI*, HFA) 200-500 >500-1000 >1000
BDP (DPI or PMDI, extrafine particle, HFA) 100-200 >200-400 >400
Budesonide (DPI or PMDI*, HFA) 200-400 >400–800 >800
Ciclesonide (PMDI, extrafine particle, HFA) 80-160 >160-320 >320
Fluticasone furoate (DPI) 100 200
Fluticasone propionate (DPI) 100-250 >250-500 >500
Fluticasone propionate (PMDI*, HFA) 100-250 >250-500 >500
Mometasone furoate (DPI) Depends on DPI device
Mometasone furoate (PMDI", HFA) 200-400 400
Children 6-11 years
Inhaled corticosteroid
Total daily ICS dose (mcg)
Low Medium High
BDP (PMDI*, HFA) 100-200 >200-400 >400
BDP (PMDI, extrafine particle, HFA) 50-100 >100-200 >200
Budesonide (DPI) 100-200 >200-400 >400
Budesonide (nebules) 250-500 >500-1000 >1000
Ciclesonide (PMDI, extrafine particle, HFA) 80 >80-160 >160
Fluticasone furoate (DPI) 50 n.a.
Fluticasone propionate (DPI) 50-100 >100-200 > 200
Fluticasone propionate (PMDI*, HFA) 50-100 >100-200 >200
BDP: beclometasone dipropionate; DPI: dry powder inhaler; HFA: hydrofluoroalkane propellant; pMDI: pressurized metered
dose inhaler. Table shows metered doses. * standard (non-fine) particle. ICS by pMDI should preferably be used with a spacer

23
Stepwise approach for adjusting treatment for individual patient needs
Once asthma treatment has been started, ongoing decisions are based on a cycle of shared decision-
making to assess the patient, adjust their treatment (pharmacological and non-pharmacological) if needed,
and review their response.
Treatment can be stepped up or down along one track using the same reliever at each step, or it can be
switched between tracks, according to the individual patient’s needs (Table 7). For patients whose asthma
is not well-controlled on a particular treatment, adherence, inhaler technique and comorbidities should be
checked before considering a different medication in the same step, or before stepping up.
Table 7: Stepwise Treatment Approach
Steps
Preferred
controller
Other controller
options
Children 6-11 years
Step 1
Recommendations are
for
• Patients with
symptoms less than
twice a month and
no exacerbation risk
factors
• Step-down treatment
for patients whose
asthma is well-
controlled on regular
ICS or LTRA
• Low dose
ICS-formoterol
taken as needed for
symptom relief
whenever SABA is
taken
• Taking ICS whenever
SABA is taken is a
possible option
Step 2
• Low dose
ICS-formoterol
taken as needed for
symptom relief (Track
1)
• Alternative Step 2
treatment for adults
and adolescents:
daily low dose ICS
plus as-needed
SABA (Track 2)
whenever SABA
is taken, either in
combination or
separate inhalers
(off-label).
• Leukotriene receptor
antagonists (LTRA)
• Daily low dose ICS-
LABA
• The preferred controller
option is regular low dose
ICS with as-needed SABA
• Other options include
taking low dose ICS
whenever SABA is taken,
using separate inhalers.
• Daily LTRA is less
effective for exacerbation
reduction
Step 3

24
• Low dose
ICS-formoterol
maintenance and
reliever therapy
(Track 1)
• Maintenance low
dose ICS-LABA plus
as-needed SABA
(Track 2)
• Medium dose ICS,
or low dose ICS plus
LTRA
• For adult patients
with rhinitis who are
allergic to house
dust mite, consider
adding sublingual
immunotherapy
(SLIT), provided
FEV1 is >70%
predicted.
• Three preferred options
for children:
o Medium dose ICS with
as-needed SABA
o Low dose ICS-LABA,
with as-needed SABA
o Maintenance and
reliever therapy with
a very low dose of
budesonide/ formoterol
(100/6 mcg once-daily,
80/4.5 mcg delivered
dose
Step 4
• Medium dose
ICS-formoterol as
maintenance and
reliever therapy
(Track 1)
• Alternative treatment
includes medium or
high dose ICS-LABA
with as-needed
SABA (Track 2)
• Add-on LAMA
for patients ≥18
years (≥6 years for
tiotropium by mist
haler) in separate or
combination (‘triple’)
inhalers.
• For adult patients
with rhinitis and
asthma who are
allergic to house dust
mite, consider adding
SLIT, provided FEV1
is >70% predicted.
• Increasing the dose of
maintenance ICS-LABA to
medium; for maintenance
and reliever therapy, the
maintenance dose may be
increased to 100/6 mcg
twice daily (metered dose
80/4.5 mcg).
• If asthma is not well-
controlled with medium
dose ICS, continue
controller, and refer for
expert advice
Step 5
• Refer for phenotypic
investigation ± add-
on treatment
- -

25
Reviewing response and adjusting treatment
Patients should preferably be seen 1–3 months after starting treatment and every 3–12 months after that,
but in pregnancy, asthma should be reviewed every 4–6 weeks to consider treatment adjustment (Table 8).
After an exacerbation, a review visit within 1 week should be scheduled.
The frequency of review depends on the patient’s initial level of symptom control, their risk factors, their
response to initial treatment, and their ability and willingness to engage in self-management with an action
plan
Table 8: Reviewing Response and Adjusting Treatment
Stepping up asthma treatment
Stepping down treatment when asthma
is well-controlled
• Sustained step-up (for at least 2–3 months): if
symptoms and/or exacerbations persist despite
2–3 months of controller treatment, assess the
following common issues before considering a
step-up
o Incorrect inhaler technique
o Poor adherence
o Modifiable risk factors, e.g. smoking
o Are symptoms due to comorbid conditions,
e.g., allergic rhinitis
• Short-term step-up (for 1–2 weeks) by clinician
or by patient with written asthma action plan,
e.g., during viral infection or allergen exposure
• Day-to-day adjustment by patient for patients
prescribed as-needed low dose ICS-formoterol
for mild asthma, or low dose ICS-formoterol as
maintenance and reliever therapy.
• Consider stepping down treatment once
good asthma control has been achieved and
maintained for 3 months, to find the lowest
treatment that controls both symptoms and
exacerbations, and minimizes side effects
• Choose an appropriate time for step-down (no
respiratory infection, patient not travelling, not
pregnant)
• Assess risk factors, including history of previous
exacerbations or emergency department visit,
and low lung function
• Document baseline status (symptom control and
lung function), provide a written asthma action
plan, monitor closely, and book a follow-up visit
• Step down through available formulations to
reduce the ICS dose by 25–50% at 2–3 month
intervals
• If asthma is well-controlled on low dose ICS or
LTRA, as-needed low dose ICS-formoterol is a
step-down option
• Do not completely stop ICS in adults or
adolescents with a diagnosis of asthma unless
this is needed temporarily to confirm the
diagnosis of asthma.
• Make sure a follow-up appointment is arranged.

26
Table 9: Options for stepping down treatment once asthma is well controlled
Current
step
Current medication
and dose
Options for stepping down Evidence
Step 5 High dose
ICS-LABA plus oral
corticosteroids (OCS)
• Continue high dose ICS-LABA and reduce OCS
dose
• Use sputum-guided approach to reducing OCS
• Alternate-day OCS treatment
• Replace OCS with high dose ICS
D
B
D
D
High dose ICS-LABA
plus other add-on
agents
• Refer for expert advice D
Step 4 Moderate to high dose
ICSLABA maintenance
treatment
• Continue combination ICS-LABA with 50% reduction
in ICS component, by using available formulations
• Discontinuing LABA may lead to deterioration
B
A
Medium dose ICS-
formoterol* as
maintenance and
reliever
• Reduce maintenance ICS-formoterol* to low dose,
and continue as-needed low dose ICS-formoterol*
reliever
D
High dose ICS plus
second controller
• Reduce ICS dose by 50% and continue second
controller
B
Step 3 Low dose ICS-LABA
maintenance
• Reduce ICS-LABA to once daily
• Discontinuing LABA may lead to deterioration
D
A
Low dose ICS-
formoterol* as
maintenance and
reliever
• Reduce maintenance ICS-formoterol* dose to
once daily and continue as-needed low dose ICS-
formoterol* reliever
C
Medium or high dose
ICS
• Reduce ICS dose by 50%
• Adding LTRA† may allow ICS dose to be stepped
down
A
B
Step 1 Low dose ICS • Once-daily dosing (budesonide, ciclesonide,
mometasone)303,304
• Switch to as-needed low dose ICS-
formoterol168,169,171
• Switch to taking ICS whenever SABA is
taken196,197,199
A
A
B
Low dose ICS or LTRA • Switch to as-needed low dose ICS
formoterol168-171
• Complete cessation of ICS in adults and
adolescents is not advised as the risk of
exacerbations is increased with SABA-only
treatment299
A
A
BDP: beclometasone dipropionate; ICS: inhaled corticosteroids; LABA: long-acting beta2-agonist; LTRA: leukotriene receptor
antagonist; OCS: oral corticosteroids. *ICS-formoterol maintenance and reliever treatment can be prescribed with low dose
budesonide-formoterol or BDP-formoterol. †Note FDA warning on neuropsychiatric effects with montelukast

27
Inhaler skills and adherence
About 80% of asthma patients cannot use their inhalers correctly and up to 50% do not adhere to treatment
regimen resulting in poor symptom control and exacerbations.
Table 10: It is important to provide skills training for effective use of inhaler devices
Choose
• Choose the most appropriate inhaler device for the patient before prescribing. Consider the
medication options (Box 3-5, p.59), the available devices, patient skills and cost.
• If different options are available, encourage the patient to participate in the choice.
• For pMDIs, use of a spacer improves delivery and (with ICS) reduces the potential for side-effects.
• Ensure that there are no physical barriers, e.g. arthritis, that limit use of the inhaler.
• Avoid use of multiple different inhaler types where possible, to avoid confusion.
Check
• Check inhaler technique at every opportunity.
• Ask the patient to show you how they use their inhaler (don’t just ask if they know how to use it).
• Identify any errors using a device-specific checklist.
Correct
• Show the patient how to use the device correctly with a physical demonstration, e.g. using a placebo
inhaler.
• Check technique again, paying attention to problematic steps.You may need to repeat this process
2–3 times.
• Only consider an alternative device if the patient cannot use the inhaler correctly after several repeats
of training.
• Re-check inhaler technique frequently. After initial training, errors often recur within 4–6 weeks.397
Confirm
• Clinicians should be able to demonstrate correct technique for each of the inhalers they prescribe.
• Pharmacists and nurses can provide highly effective inhaler skills training.
Factors contributing to poor adherence include
• Medication/regimen factors
o Difficulties using inhaler device (e.g. arthritis)
o Burdensome regimen (e.g. multiple times per day)
o Multiple different inhalers
• Unintentional poor adherence
o Misunderstanding about instructions
o Forgetfulness
o Absence of a daily routine
o Cost

28
• Intentional poor adherence
o Perception that treatment is not necessary
o Denial or anger about asthma or its treatment
o Inappropriate expectations
o Concerns about side-effects (real or perceived)
o Dissatisfaction with health care providers
o Stigmatization
o Cultural or religious issues
o Cost
Strategies to improve adherence are
• Identifying patients with adherence problems
• Ask an empathic question, e.g., “Most patients don’t take their inhaler exactly as prescribed. In the last
4 weeks, how many days a week have you been taking it? 0 days a week, or 1, or 2 days [etc.]?”
, or “Do
you find it easier to remember your inhaler in the morning or night?”
• Check medication usage, from prescription date, inhaler date/dose counter, dispensing records
• Ask about attitudes and beliefs about asthma and medications
• Improve adherence through
• Shared decision-making for medication and dose choice
• Inhaler reminders for missed doses
• Comprehensive asthma education with home visits by asthma nurses
• Clinicians reviewing feedback about their patients’ dispensing records
• An automated voice recognition program with telephone messages triggered when refills were due or
overdue
• Directly observed controller therapy at school, with telemedicine oversight
• Electronic inhaler monitoring to identify poor adherence in patients with difficult-to-treat asthma

29
Treating modifiable risk factors
Exacerbation risk can be minimized by optimizing asthma medications, and by identifying and treating
modifiable risk factors. Some examples of risk modifiers with consistent high quality evidence are:
Exacerbation risk can be reduced both by optimizing asthma medications, and by identifying and treating
modifiable risk factors (Table 11). Not all risk factors require or respond to a step up in controller treatment.
Table 11: Treating potentially modifiable risk factors to reduce exacerbations
Risk factor Treatment strategy
Any patient with ≥1 risk
factor for exacerbations
(including poor symptom
control)
• Ensure patient is prescribed an ICS-containing controller.
• Maintenance and reliever therapy (MART) with ICS-formoterol reduces risk
of severe exacerbations compared with if the reliever is SABA.
• Ensure patient has a written action plan appropriate for their health literacy.
• Review patient more frequently than low-risk patients.
• Check inhaler technique and adherence frequently.
• Identify any modifiable risk factors (Box 2-2, p.36)
≥1 severe exacerbation
in last year
• ICS-formoterol maintenance and reliever regimen reduces risk of severe
exacerbations compared with if the reliever is SABA.
• Consider stepping up treatment if no modifiable risk factors.
• Identify any avoidable triggers for exacerbations.
Exposure to tobacco
smoke
• Encourage smoking cessation by patient/family; provide advice and
resources.
• Consider higher dose of ICS if asthma poorly controlled.
Low FEV1, especially if
<60% predicted
• Consider trial of 3 months’ treatment with high dose ICS.
• Consider 2 weeks’ OCS, but take short- and long-term risks into account
• Exclude other lung disease, e.g. COPD.
• Refer for expert advice if no improvement.
Obesity • Strategies for weight reduction
• Distinguish asthma symptoms from symptoms due to deconditioning,
mechanical restriction, and/or sleep apnea.
Major psychological
problems
• Arrange mental health assessment.
• Help patient to distinguish between symptoms of anxiety and asthma;
provide advice about management of panic attacks.
Major socioeconomic
problems
• Identify most cost-effective ICS-based regimen.
Confirmed food allergy • Appropriate food avoidance; injectable epinephrine.
Allergen exposure if
sensitized
• Consider trial of simple avoidance strategies; consider cost.
• Consider step up of controller treatment.
• Consider adding SLIT in symptomatic adult HDM-sensitive patients with
allergic rhinitis despite ICS, provided FEV1 is >70% predicted.
Sputum eosinophilia
(limited centers)
• Increase ICS dose independent of level of symptom control.
COPD: chronic obstructive pulmonary disease; FEV1: forced expiratory volume in 1 second; HDM: house dust mite;
ICS: inhaled corticosteroids; OCS: oral corticosteroids; SLIT: sublingual immunotherapy

30
Non-pharmacological strategies and interventions
In addition to medications, other therapies and strategies may be considered where relevant, to assist in
symptom control and risk reduction (Table 12).
Table 11: Non-pharmacological interventions - summary
Cessation of
smoking and
ETS exposure
• At every visit, strongly encourage people with asthma who smoke to quit. Provide
access to counseling and smoking cessation programs (if available).
• Advise parents/carers of children with asthma not to smoke and not to allow
smoking in rooms or cars that their children use.
• Strongly encourage people with asthma to avoid environmental smoke exposure.
• Assess smokers/ex-smokers for COPD or overlapping features of asthma and
COPD (asthma– COPD overlap), as additional treatment strategies may be
required.
Physical activity • Encourage people with asthma to engage in regular physical activity for its general
health benefits.
• Provide advice about prevention of exercise-induced bronchoconstriction with
regular ICS.
• Provide advice about prevention of breakthrough exercise-induced
bronchoconstriction with
o Warm-up before exercise
o SABA before exercise
o Low dose ICS-formoterol before exercise
• Regular physical activity improves cardiopulmonary fitness, and can have a small
benefit for asthma control and lung function, including with swimming in young
people with asthma.
• There is little evidence to recommend one form of physical activity over another.
Avoidance of
occupational
exposures
• Ask all patients with adult-onset asthma about their work history and other
exposures
• In management of occupational asthma, identify and eliminate occupational
sensitizers as soon as possible, and remove sensitized patients from any further
exposure to these agents.
• Patients with suspected or confirmed occupational asthma should be referred for
expert assessment and advice, if available.
Avoidance of
medications
that may make
asthma worse
• Always ask about asthma before prescribing NSAIDs, and advise patients to stop
using them if asthma worsens.
• Always ask people with asthma about concomitant medications
• Aspirin and NSAIDs (non-steroidal anti-inflammatory drugs) are not generally
contraindicated unless there is a history of previous reactions to these agents
• Decide about prescription of oral or ophthalmic beta-blockers on a case-by-case
basis.
• Initiate treatment under close medical supervision by a specialist.
• If cardioselective beta-blockers are indicated for acute coronary events, asthma
is not an absolute contra-indication, but the relative risks/benefits should be
considered.
Healthy diet • Encourage patients with asthma to consume a diet high in fruit and vegetables for
its general health benefits.

31
Avoidance of
indoor allergens
• Allergen avoidance is not recommended as a general strategy in asthma.
• For sensitized patients, there is limited evidence of clinical benefit for asthma in
most circumstances with single-strategy indoor allergen avoidance.
• Remediation of dampness or mold in homes reduces asthma symptoms and
medication use in adults.
• For patients sensitized to house dust mite and/or pets, there is limited evidence of
clinical benefit for asthma with avoidance strategies (only in children) .
• Allergen avoidance strategies are often complicated and expensive, and there are
no validated methods for identifying those who are likely to benefit.
Weight
reduction
• Include weight reduction in the treatment plan for obese patients with asthma.
• For obese adults with asthma a weight reduction program plus twice-weekly
aerobic and strength exercises is more effective for symptom control than weight
reduction alone.
Breathing
exercises
• Breathing exercises may be a useful supplement to asthma pharmacotherapy
for symptoms and quality of life, but they do not reduce exacerbation risk or have
consistent effects on lung function.
Avoidance
of indoor air
pollution
• Encourage people with asthma to use non-polluting heating and cooking sources,
and for sources of pollutants to be vented outdoors where possible.
Avoidance
of outdoor
allergens
• For sensitized patients, when pollen and mold counts are highest, closing windows
and doors, remaining indoors, and using air conditioning may reduce exposure to
outdoor allergens.
Dealing with
emotional
stress
• Encourage patients to identify goals and strategies to deal with emotional stress if it
makes their asthma worse.
• There is insufficient evidence to support one stress-reduction strategy over another,
but relaxation strategies and breathing exercises may be helpful.
• Arrange a mental health assessment for patients with symptoms of anxiety or
depression.
Avoidance of
outdoor air
pollutants/
weather
conditions
• During unfavorable environmental conditions (very cold weather or high air
pollution) it may be helpful to stay indoors in a climate-controlled environment, and
to avoid strenuous outdoor physical activity; and to avoid polluted environments
during viral infections, if feasible.
Avoidance of
foods and food
chemicals
• Food avoidance should not be recommended unless an allergy or food chemical
sensitivity has been clearly demonstrated, usually by carefully supervised oral
challenges.
• For confirmed food allergy, food allergen avoidance may reduce asthma
exacerbations.
• If food chemical sensitivity is confirmed, complete avoidance is not usually
necessary, and sensitivity often decreases when asthma control improves.
NSAID: non-steroidal anti-inflammatory drugs; SABA: short-acting beta2-agonist

32
Treatment in specific populations or contexts
Pregnancy
• Asthma control often changes during pregnancy. For baby and mother, the advantages
of actively treating asthma markedly outweigh any potential risks of usual controller
and reliever medications.
• Down-titration has a low priority in pregnancy, and ICS should not be stopped.
• Exacerbations should be treated aggressively.
Rhinitis and
sinusitis
• Rhinitis and sinusitis often coexist with asthma.
• Chronic rhinosinusitis and nasal polyposis are associated with more severe asthma.
• Treatment of allergic rhinitis or chronic rhinosinusitis reduces nasal symptoms but
does not improve asthma control
Obesity
• Document the diagnosis of asthma in the obese, to avoid over- or under-treatment.
• Include weight reduction in the treatment plan for obese patients with asthma; even
5–10% weight loss can improve asthma control
The elderly
• Comorbidities and their treatment may complicate asthma management.
• Factors such as arthritis, eyesight, inspiratory flow, and complexity of treatment
regimens should be considered when choosing medications and inhaler devices.
Gastro-
esophageal
reflux
disease
(GERD)
• GERD is commonly seen in asthma.
• Symptomatic reflux should be treated for its general health benefits, but there is no
benefit from treating asymptomatic reflux in asthma.
Anxiety and
depression
• Anxiety and depression are commonly seen in people with asthma, and are
associated with worse symptoms and quality of life.
• Patients should be assisted to distinguish between symptoms of anxiety and of
asthma.
Aspirin-
exacerbated
respiratory
disease
(AERD)
• A history of exacerbation following ingestion of aspirin or other NSAIDs is highly
suggestive.
• Patients often have severe asthma and nasal polyposis.
• Confirmation of the diagnosis of AERD may require challenge in a specialized center
with resuscitation facilities, but avoidance of NSAIDs may be recommended on the
basis of a clear history.
• ICS are the mainstay of treatment, but OCS may be required; LTRA may also be
useful.
• Desensitization is sometimes effective but must be done under specialist care; there
is a significantly increased risk of adverse effects such as gastritis and gastrointestinal
bleeding.
Food
allergy and
anaphylaxis
• Food allergy is rarely a trigger for asthma symptoms. It must be assessed with
specialist testing.
• Confirmed food allergy is a risk factor for asthma-related death.
• Good asthma control is essential; patients should also have an anaphylaxis plan and
be trained in appropriate avoidance strategies and use of injectable epinephrine.
Surgery
• Whenever possible, good asthma control should be achieved preoperatively.
• Ensure that controller therapy is maintained throughout the perioperative period.
• Patients on long-term high dose ICS, or having more than 2 weeks’ oral corticosteroids
in the past 6 months, should receive intra-operative hydrocortisone to reduce the risk
of adrenal crisis
LMIC
• The basic principles and goals of asthma treatment are the same in low- and middle-
income countries as they are in high-income countries.
• However, common barriers to effective long-term asthma care include a lack of inhaled
medicines and healthcare systems that prioritize acute care over chronic care.
• Track 2 treatment, while less effective in reducing asthma exacerbations, may be
preferable in situations where Track 1 treatment is not currently available or affordable.

33
Difficult-to-treat and severe asthma in adults and adolescents
What are difficult to treat and severe asthma?
• Difficult-to-treat asthma is defined as uncontrolled asthma despite using medium or high doses of
ICS-LABA or requiring high doses of ICS-LABA to maintain reasonable symptom control and reduce
exacerbations. It does not imply a “tough patient.”
• Severe asthma is defined as asthma that persists despite optimal high-dose ICS-LABA therapy and
treatment of contributing factors or worsens when high-dose treatment is reduced. Severe asthma
affects 3–10% of people with asthma.
• Patients with severe asthma face a significant physical, mental, emotional, social, and financial
burden. It is frequently linked to multimorbidity.
How should these patients be assessed?
• Identify and manage factors contributing to symptoms, poor quality of life, or exacerbations in all
patients with difficult-to-treat asthma.
• Seek expert advice at any stage or if asthma does not respond to treatment optimization.
• Patients with persistent symptoms and/or exacerbations despite high-dose ICS should have their
clinical or inflammatory phenotype evaluated, as this may help guide the addition of treatment.
Management of severe asthma
• Add-on treatments for severe asthma include LAMA, LTRA, low-dose azithromycin (adults), and
biologic agents for severe asthma, depending on the inflammatory phenotype and other clinical
features.
• Low-dose administration Because of the serious long-term side effects, OCS should only be used as
a last resort if no other options are available.
• Evaluate any additional treatments, discontinue ineffective treatments, and consider other options.
• If available, seek specialist multidisciplinary team care for severe asthma.
• Continue to optimize patient care for patients with severe asthma in collaboration with the primary
care clinician, considering the patient’s social and emotional needs.
• If available and relevant, invite patients with severe asthma to participate in a registry or clinical trial
to help fill evidence gaps.

34
Figure shows the GINA severe asthma decision tree
Investigate and manage difficult-to-treat asthma in adults and adolescents
DIAGNOSIS:
“Difficult-
to-treat
asthma”
Consider referring to specialist or severe asthma clinic at any stage
3Optimize management,
including:
• Asthma education
• Optimize treatment (e.g. check and
correct inhaler technique and
adherence; switch to ICS-formoterol
maintenance and reliever therapy,
if available)
• Consider non-pharmacological
interventions (e.g. smoking
cessation, exercise, weight loss,
mucus clearance, influenza and
COVID-19 vaccination)
• Treat comorbidities and
modifiable risk factors
• Consider non-biologic add-on
therapy (e.g. LABA, LAMA,
LM/LTRA, if not used)
• Consider trial of high dose ICS-
LABA, if not used
1Confirm the diagnosis
(asthma/differential
diagnoses)
2Look for factors
contributing to symptoms,
exacerbations and poor
quality of life:
• Incorrect inhaler technique
• Suboptimal adherence
• Comorbidities including obesity,
GERD, chronic rhinosinusitis, OSA
• Modifiable risk factors and
triggers at home or work, including
smoking, environmental exposures,
allergen exposure (if sensitized);
medications such as beta-blockers
and NSAIDs
• Overuse of SABA relievers
• Medication side effects
• Anxiety, depression and social
difficulties
4 Review response after ~3-6 months
Is asthma
still uncontrolled?
Does
asthma become
uncontrolled when
treatment is stepped
down?
Continue optimizing
management
Consider stepping down
treatment, OCS first
(if used)
yes
yes
no
no
Restore previous dose
If not done by now, refer to
a specialist, if possible
DIAGNOSIS:
“Severe
asthma”
GP OR SPECIALIST CARE
For adolescents and
adults with symptoms
and/or exacerbations
despite medium or
high dose ICS-LABA,
or taking maintenance
OCS
-
N
O
T
C
O
P
Y
O
R
D
I
S
T
R
I
B
U
T
E
diagnosis,
confirmation
intervention,
treatment
Key
decision,
filters
Type 2 inflammation
Not currently eligible
for T2-targeted biologic
therapy
Assess and treat severe asthma phenotypes
Continue to optimize management as in section 3 (including inhaler technique, adherence, comorbidities, non-pharmacologic strategies)
5 Investigate further and
provide patient support
6 Assess the severe asthma phenotype
• Investigate for comorbidities/differential
diagnoses and treat/refer as appropriate
- Consider: CBC, CRP, IgG, IgA, IgM,
IgE, fungal precipitins; CXR and/or
HRCT chest; DLCO; DEXA scan
- Skin prick testing or specific IgE for
relevant allergens, if not already done
- Consider screening for adrenal
insufficiency in patients taking
maintenance OCS or high dose ICS
- If blood eosinophils ≥300/μl, look for
and treat non-asthma causes, includ-
ing parasites (e.g. Strongyloides
serology, or stool examination)
- If hypereosinophilia e.g. ≥1500/μl,
consider causes such as EGPA
- Other directed testing (e.g. ANCA, CT
sinuses, BNP, echocardiogram)
based on clinical suspicion
• Consider need for social/psychological
support
• Involve multidisciplinary team care
(if available)
• Invite patient to enroll in registry (if
available) or clinical trial (if appropriate)
yes
no
7Consider other treatments
yes
no
Is add-on
Type 2 biologic
therapy available/
affordable?
If add-on Type 2-targeted biologic therapy is
NOT available/affordable
• Consider higher dose ICS, if not used
• Consider other add-on therapy
(e.g. LAMA, LM/LTRA, low dose azithromycin)
• As last resort, consider add-on low dose OCS, but
implement strategies to minimize side-effects
• Stop ineffective add-on therapies
• Review the basics: differential diagnosis, inhaler technique, adherence,
comorbidities, side-effects
• Avoid exposures (tobacco smoke, allergens, irritants)
• Consider investigations (if available and not done)
- Sputum induction
- High resolution chest CT
- Bronchoscopy for alternative/additional diagnoses
• Consider trial of add-on treatments (if available and not already tried)
- LAMA
- Low dose azithromycin
- Anti-IL4R*if taking maintenance OCS
- Anti-TSLP* maintenance OCS
- As last resort, consider add-on low dose OCS, but implement strategies
to minimize side-effects
• Consider bronchial thermoplasty (+ registry)
• Consider adherence tests
• Consider increasing the ICS dose for 3-6 months
• Consider add-on non-biologic treatment for
specific Type 2 clinical phenotypes, e.g. AERD,
ABPA, chronic rhinosinusitis, nasal polyposis,
atopic dermatitis
Could patient
have Type 2 airway
inflammation?
Go to section 10
Type 2 airway inflammation
No evidence of Type 2 airway inflammation
• Blood eosinophils ≥150/µl
and/or
• FeNO ≥20 ppb and/or
• Sputum eosinophils ≥2%, and/or
• Asthma is clinically allergen-
driven
(Repeat blood eosinophils and
FeNO up to 3x, at least 1-2
weeks after OCS or on lowest
possible OCS dose)
Note: these are not the criteria for
add-on biologic therapy (see 8)
*Check local eligibility criteria for specific biologic
therapies as these may vary from those listed
Go to section 10

35
Choose one
if eligible*;
trial for at least
4 months and
assess response
yes
unclear
no
no
no
no
no
no Little/no response
to T2-targeted therapy
Good response
to T2-targeted therapy
Assess and treat severe asthma phenotypes cont’d
Continue to optimize management as in section 3 (including inhaler technique, adherence, comorbidities, non-pharmacologic strategies)
8 Consider add-on biologic Type 2-targeted treatments
• Consider add-on Type 2-
targeted biologic therapy
for patients with
exacerbations or poor
symptom control on high
dose ICS-LABA, who have
evidence of Type 2
inflammation*
• Consider local payer
eligibility criteria*,
comorbidities and
predictors of response
when choosing between
available therapies
• Also consider cost, dosing
frequency, route (SC or IV),
patient preference
Eligible for none? Return to section 7
Is the patient eligible for anti-IgE for severe allergic asthma?*
• Sensitization on skin prick testing or specific IgE
• Total serum IgE and weight within dosage range
• Exacerbations in last year
What factors may predict good
asthma response to anti-IgE?
• Blood eosinophils ≥260/µl ++
• FeNO ≥20 ppb +
• Allergen-driven symptoms +
• Childhood-onset asthma +
no
no
Good
asthma
response?*
STOP add-on
Consider switching
to a different Type
2-targeted therapy,
if eligible*
Which biologic
is appropriate to
start first?
Anti-IgE (omalizumab)
asthma response to anti-IL5/5R?
• Higher blood eosinophils +++
• More exacerbations in
previous year +++
• Adult-onset of asthma ++
• Nasal polyposis ++
Is the patient eligible for anti-IL5 / anti-IL5R for severe eosinophilic asthma?*
• Blood eosinophils, e.g. ≥150/µl or ≥300/µl
Anti-IL5 / Anti-IL5R (benralizumab, mepolizumab, reslizumab)
Is the patient eligible for anti-IL4R for severe eosinophilic/Type 2 asthma?*
• Blood eosinophils ≥150 and ≤1500/μl, or FeNO ≥25 ppb,
or taking maintenance OCS
asthma response to anti-IL4R?
• Higher FeNO +++
Anti-IL4R (dupilumab)
Is the patient eligible for anti-TSLP for severe asthma?*
asthma response to anti-TSLP?
• Higher FeNO +++
Anti-TSLP (tezepelumab)
Extend trial to
6-12 months*
Eligibility Predictors of asthma response
No evidence of Type 2 airway inflammation. Go to section 10
No evidence of Type 2 airway inflammation
Monitor / Manage severe asthma treatment
Continue to optimize management
10 Continue to optimize management as in section 3, including:
9Review response
• Asthma: symptom control, exacerbations, lung function
• Type 2 comorbidities e.g. nasal polyposis, atopic dermatitis
• Medications: treatment intensity, side-effects, affordability
• Patient satisfaction
If good response to Type 2-targeted therapy
• Re-evaluate the patient every 3-6 months*
• For oral treatments: consider decreasing/stopping OCS first (and
check for adrenal insufficiency), then stopping other add-on medication
• For inhaled treatments: consider decreasing after 3-6 months;
continue at least moderate dose ICS-LABA
• Re-evaluate need for ongoing biologic therapy
• Order of reduction of treatments based on observed benefit, potential
side-effects, cost and patient preference
If no good response to Type 2-targeted therapy
• Stop the biologic therapy
• Review the basics: differential diagnosis, inhaler technique,
adherence, comorbidities, side-effects, emotional support
• Consider high resolution chest CT (if not done)
• Reassess phenotype and treatment options
- Induced sputum (if available)
- Consider add-on low dose azithromycin
- Consider bronchoscopy for alternative/additional diagnoses
- As last resort, consider add-on low dose OCS, but implement
strategies to minimize side-effects
- Consider bronchial thermoplasty (+ registry)
• Do not stop ICS
no
yes
No evidence of Type 2 airway inflammation. Go to section 10
• Inhaler technique
• Adherence
• Comorbidity management
• Non-pharmacologic strategies
• Patients’ social/emotional needs
• Two-way communication with GP for ongoing care

36
Asthma flare-ups (exacerbations)
A flare-up or exacerbation is an acute or sub-acute worsening in symptoms and lung function from the
patient’s usual status; occasionally it may be the initial presentation of asthma.
The management of worsening asthma and exacerbations should be considered as a continuum, from
self-management by the patient with a written asthma action plan, through to management of more severe
symptoms in primary care, the
Patients with features indicating increased risk of asthma-related death should be flagged for
more frequent review. These features include:
• History: A history of near-fatal asthma (ever) requiring intubation and ventilation; hospitalization or
emergency care for asthma in the last year
• Medications: not currently using ICS, or with poor adherence with ICS; currently using or recently
stopped OCS (an indication of recent severity); over-use of SABA, especially more than 1 canister per
month
• Comorbidities: history of psychiatric disease or psychosocial problems; confirmed food allergy in a
patient with asthma
• Lack of a written asthma action plan
Written asthma action plans
All patients should be provided with a written asthma action plan appropriate for their level of asthma
control and health literacy, so they know how to recognize and respond to worsening asthma (Figure 9)
A written (i.e. documented) asthma action plan may be printed, digital, or pictorial, to suit the patient’s
needs and literacy..
Action plans can be based on symptoms and/or (in adults) PEF. Patients who deteriorate quickly should be
advised to seek urgent care immediately.

37
Effective asthma self-management education requires:
• Self-monitoring of symptoms and/or lung function
• Written asthma action plan
• Regular medical review
All patients
Increase reliever
Early increase in controller
as below
Review response
EARLY OR MILD LATE OR SEVERE
If PEF or FEV,
<60% best, or not
improving after
48 hours
Continue reliever
Continue controller
Add prednisolone*
40-50 mg/day
Contact doctor
Medication
Short-term change (1–2 weeks)
for worsening asthma
Evidence
level
Increase usual reliever:
Low dose ICS-formoterol†
Increase frequency of as-needed ICS-formoterol†
A
Short-acting beta2-agonist
(SABA)
Increase frequency of SABA use
For pMDI, add spacer
A
A
Increase usual controller:
Maintenance and reliever
ICS-formoterol †
Continue maintenance ICS-formoterol and increase reliever
ICS-formoterol as needed.†
A
Maintenance ICS with
SABA as reliever
In adults and adolescents, quadruple ICS dose. In children
with high adherence, 5x increase in ICS dose is not effective.
B
Maintenance ICS-
formoterol with SABA as
reliever †
Quadruple maintenance ICS-formoterol. † B
Maintenance ICS plus
other LABA with SABA as
reliever
Step up to higher dose formulation of ICS plus other LABA
In adults, consider adding a separate ICS inhaler to
quadruple ICS dose.
B
D
Add oral corticosteroids (OCS) and contact doctor; review before ceasing
OCS (prednisone or
prednisolone)
Add OCS for severe exacerbations (e.g. PEF or FEV1 <60%
personal best or predicted), or patient not responding to
treatment over 48 hours. Once started, morning dosing is
preferable.
Adults: prednisolone 40-50mg/day, usually for 5–7 days.
Children 6–11 years: 1–2 mg/kg/day (maximum 40 mg)
usually for 3–5 days.
Tapering is not needed if OCS are prescribed for <2 weeks.
A
D
B
Figure 9: Written asthma action plan for self-management of worsening asthma
in adults and adolescents

38
Managing exacerbations in primary or acute care
A brief focused history and relevant physical examination should be conducted concurrently with the
prompt initiation of therapy, and findings documented in the notes. If the patient shows signs of a severe or
life-threatening exacerbation, treatment with SABA, controlled oxygen and systemic corticosteroids should
be initiated while arranging for the patient’s urgent transfer to an acute care facility where monitoring and
expertise are more readily available.
Milder exacerbations can usually be treated in a primary care setting, depending on resources and expertise
(Figure 10)
Figure 10: Management of asthma exacerbations in primary care
O2: oxygen; PEF: peak expiratory flow; SABA: short-acting beta2-agonist (doses are for salbutamol)

39
Reviewing response
• Monitor patients closely and frequently during treatment, and titrate treatment according to response.
• Transfer to higher level care if worsening or failing to respond.
• Decide on need for hospitalization based on clinical status, symptoms and lung function, response to
treatment, recent and history of exacerbations, and ability to manage at home.
• Before discharge, arrange ongoing treatment.
o For most patients, prescribe regular controller therapy (or increase current dose) to reduce the risk
of further exacerbations.
o Continue increased controller doses for 2–4 weeks, and reduce reliever to as-needed dosing.
o Check inhaler technique and adherence. Provide an interim written asthma action plan.
o Arrange early follow-up after any exacerbation, within 2–7 days (for children, within 1-2 working days).
o Consider early referral for specialist advice after hospitalization, or for patients with repeated ED
presentation
Follow-up after an exacerbation
• Exacerbations often represent failures in chronic asthma care, and they provide opportunities to review
the patient’s asthma management.
• All patients must be followed up regularly by a health care provider until symptoms and lung function
return to normal.
• Take the opportunity to review:
o The patient’s understanding of the cause of the exacerbation
o Modifiable risk factors for exacerbations, e.g. smoking
o Understanding of purposes of medications, and inhaler technique skills
o Adherence with ICS and OCS as this may fall rapidly after discharge
• Written asthma action plan – revise if necessary Comprehensive post-discharge programs that include
optimal controller management, inhaler technique, self-monitoring, written asthma action plan and
regular review are cost-effective and are associated with significant improvement in asthma outcomes.

40
Indications for referral for expert advice
While the majority of people with asthma can usually be managed in primary care, some clinical situations
warrant referral for expert advice regarding diagnosis and/or management (Table 13).
Table 13: Indications for considering referral for expert advice, where available
Difficulty confirming the diagnosis of asthma
• Patient has symptoms of chronic infection, or features suggesting a cardiac or other nonpulmonary
cause immediate referral recommended)
• Diagnosis is unclear even after a trial of therapy with ICS or systemic corticosteroids
• Patients with features of both asthma and COPD, if there is doubt about priorities for treatment
Suspected occupational asthma
• Refer for confirmatory testing and identification of sensitizing or irritant agent, specific advice about
eliminating exposure and pharmacological treatment.
Persistent or severely uncontrolled asthma or frequent exacerbations
• Patient’s symptoms remain uncontrolled, or patient has ongoing exacerbations or low lung function
despite correct inhaler technique and good adherence with Step 4 treatment (medium dose ICS-
LABA).
• Before referral, depending on the clinical context, identify and treat modifiable risk factors and
comorbidities
• Patient has frequent asthma-related health care utilization (e.g. multiple ED visits or urgent primary
care visits).
Any risk factors for asthma-related death
• Near-fatal asthma attack (ICU admission, or mechanical ventilation for asthma) at any time in the past
• Suspected or confirmed anaphylaxis food allergy in a patient with asthma
Evidence of, or risk of, significant treatment side-effects
• Patients with significant side-effects from treatment
• Need for long-term oral corticosteroid use
• Frequent courses of oral corticosteroids (e.g. two or more courses a year)
Symptoms suggesting complications or sub-types of asthma
• E.g. aspirin-exacerbated respiratory disease; allergic bronchopulmonary aspergillosis
Additional reasons for referral in children 6–11 years
• Doubts about diagnosis of asthma e.g. respiratory symptoms are not responding well to treatment in a
child who was born prematurely
• Symptoms or exacerbations remain uncontrolled despite medium dose ICS with correct inhaler
technique and good adherence
• Suspected side-effects of treatment (e.g. growth delay)
• Concerns about the child’s welfare or well-being
ED: emergency department; ICS: inhaled corticosteroids; ICU: intensive care unit

41
Asthma, COPD And asthma COPD overlap (ACO)
‘Asthma’ and ‘COPD’ are umbrella labels for heterogeneous conditions characterized by chronic airway
and/or lung disease.
• Asthma and COPD each include several different clinical phenotypes, and are likely to have several
different underlying mechanisms, some of which may be common to both asthma and COPD.
• The terms ‘asthma-COPD overlap’ (ACO) or ‘asthma+COPD’ are simple descriptors for patients who
have features of both asthma and COPD.
Diagnosis in patients with chronic respiratory symptoms involves a stepwise approach, first recognizing
that the patient is likely to have chronic airways disease, then syndromic categorization as characteristic
asthma, characteristic COPD, with features of both or having other conditions such as bronchiectasis.
• Lung function testing is essential for confirming persistent airflow limitation, but variable airflow
obstruction can be detected with serial peak flow measurements and/or measurements before and after
bronchodilator (Table 14)
Table 14: Specialized investigations sometimes used in distinguishing asthma and COPD
Asthma COPD
Lung function tests
DLCO Normal (or slightly elevated) Often reduced
Arterial blood gases Normal between exacerbations May be chronically abnormal between
Airway hyperresponsiveness
(AHR)
Not useful on its own in distinguishing asthma from COPD, but higher
levels of AHR favor asthma
Imaging
High resolution CT Scan
Usually normal but air trapping
and increased bronchial wall
thickness may be observed.
Low attenuation areas denoting either
air trapping or emphysematous change
can be quantitated; bronchial wall
thickening and features of pulmonary
hypertension may be seen
Inflammatory biomarkers
A positive test for atopy
(specific IgE and/or skin
prick test to aeroallergens)
Increases probability of allergic
asthma; not essential for
diagnosis of asthma
Conforms to background prevalence;
does not rule out COPD
FeNO
A high level (>50 ppb) in
non-smokers is moderately
associated with eosinophilic
airway inflammation.
• Usually normal
• Low in current smokers
Blood eosinophilia
Supports diagnosis of
eosinophilic airway inflammation
May be present in COPD including
during exacerbations
Sputum inflammatory cell
analysis
Role in differential diagnosis is not established in large populations
DLCO: diffusing capacity of the lungs for carbon monoxide; FeNO: fractional concentration of exhaled nitric oxide;
IgE: immunoglobulin E

42
There are extremely important differences in treatment recommendations for asthma and COPD (Figure
11). Lung function testing treatment with LABA and/or LAMA alone (i.e., without ICS) is recommended
for initial treatment in COPD, but is contraindicated in asthma due to the risk of severe exacerbations and
death.
Several studies have also shown that patients with diagnoses of both asthma and COPD are at increased
risk of hospitalization or death if they are treated with LABA compared with ICS-LABA
Initial treatment for safety and clinical efficacy
For asthma
• ICS are essential either alone or in combination with a long-acting bronchodilator (LABA), to reduce the
risk of severe exacerbations and death.
• Do not treat with LABA and/or long-acting muscarinic antagonist (LAMA) alone without ICS.
• For patients with features of both asthma and COPD, treat as asthma.
• ICS-containing therapy is important to reduce the risk of severe exacerbations and death.
• Do not give LABA and/or LAMA alone without ICS.
For COPD
• Initial treatment with LAMA and/or LABA, with as-needed SABA;add ICS for patients with hospitalizations,
≥2 exacerbations/year requiring OCS, or blood eosinophils ≥300/µl.
• All patients should be provided with structured education especially focusing on inhaler technique
and adherence as well as being assessed for, and receive appropriate treatment for, other clinical
problems, including advice about smoking cessation, immunizations, physical activity, and management
of comorbidities.
Specialist referral for additional investigations is encouraged, as patients with asthma +COPD often have
worse outcomes than those with asthma or COPD alone.

43
CLINICAL PHENOTYPE - ADULTS WITH CHRONIC RESPIRATORY SYMPTOMS
(dyspnea, cough, chest tightness, wheeze)
INITIAL PHARMACOLOGICAL TREATMENT
(as well as treating comorbidities and risk factors. See Box 3-5A)
REVIEW PATIENT AFTER 2-3 MONTHS. REFER FOR EXPERT ADVICE IF DIAGNOSTIC
UNCERTAINTY OR INADEQUATE RESPONSE
HIGHLY LIKELY TO BE ASTHMA
if several of the following features
TREAT AS ASTHMA
HISTORY
• Symptoms vary over time and in
intensity
- Triggers may include laughter,
exercise, allergens, seasonal
- Onset before age 40 years
- Symptoms improve spontaneously
or with bronchodilators (minutes)
or ICS (days to weeks) • Current
asthma diagnosis, or asthma
diagnosis in childhood
LUNG FUNCTION
• Variable expiratory airflow limitation
• Persistent airflow limitation may be
present
• ICS-CONTAINING TREATMENT IS
ESSENTIAL to reduce risk of severe
exacerbations and death. See Box
3-5A
- As-needed low dose ICS-formoterol
may be used as reliever. See Box
3-5A
• DO NOT GIVE LABA and/or LAMA
without ICS
• Avoid maintenance OCS
HISTORY
• Symptoms intermittent or episodic
- May have started before or after
age 40
• May have a history of smoking and/
or other toxic exposures, or history of
low birth weight or respiratory illness
such as tuberculosis
• Any of asthma features at left (e.g.
common triggers; symptoms improve
spontaneously or with bronchodilators
or ICS; current asthma diagnosis or
asthma diagnosis in childhood)
LUNG FUNCTION
• Persistent expiratory airflow limitation
• With or without bronchodilator
reversibilitylimitation
• ICS-CONTAINING TREATMENT IS
ESSENTIAL to reduce risk of severe
exacerbations and death. See Box
3-5A
• Add-on LABA and/or LAMA usually
also needed
• Additional COPD treatments as per
GOLD
• DO NOT GIVE LABA and/or LAMA
without ICS
• Avoid maintenance OCS
HISTORY
• Dyspnea persistent (most days)
- Onset after age 40 years
- Limitation of physical activity
- May have been preceded by cough/
sputum
- Bronchodilator provides only limited
relief
• History of smoking and/or other
toxic exposure, or history of low birth
weight or respiratory illness such as
tuberculosis
• No past or current diagnosis of
asthma
LUNG FUNCTION
• Persistent expiratory airflow limitation
• With or without bronchodilator
reversibility
• TREAT AS COPD (see GOLD
report)
- Initially LAMA and/or LABA
- Add ICS as per GOLD for
patients with hospitalizations, 22
exacerbations/year requiring OCS,
or blood eosinophils 2300/ul
• Avoid high dose ICS, avoid
maintenance OCS
• Reliever containing ICS is not
recommended
LIKELY TO BE COPD
if several of the following features
TREAT AS COPD
FEATURES OF BOTH
ASTHMA + COPD
TREAT AS ASTHMA
Figure 11: Approach to initial treatment in patients with asthma and/or COPD

44
Diagnosis and management of asthma in children 5 years and younger
Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity
from chronic disease as measured by school absences, emergency department visits and hospitalizations.
Asthma often begins in early childhood; in up to half of people with asthma, symptoms commence during
childhood.
• Onset of asthma is earlier in males than females
• It may be challenging to make a confident diagnosis of asthma in children 5 years and younger, because
episodic respiratory symptoms such as wheezing and cough are also common in children without
asthma, particularly in those 0– 2 years old, and it is not possible to routinely assess airflow limitation or
bronchodilator responsiveness in this age group.
• A probability-based approach, based on the pattern of symptoms during and between viral respiratory
infections, may be helpful for discussion with parents/carers (Table 15).
Symptoms suggestive of asthma in children 5 years and younger
Asthma diagnosis in children 5 years and younger can often be based on:
• Symptom patterns (recurrent episodes of wheeze, cough, breathlessness (typically manifested by
activity limitation), and nocturnal symptoms or awakenings)
• Presence of risk factors for development of asthma, such as family history of atopy, allergic sensitization,
allergy or asthma, or a personal history of food allergy or atopic dermatitis
• Therapeutic response to controller treatment.
• Exclusion of alternate diagnoses

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GINA 2022 Guidelines.pdf