Acute asthma exacerbation in adults
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
Look out for this icon: for treatment options that are affected, or added, as a result of your patient's comorbidities.
life-threatening exacerbation or impending respiratory failure
1st line – assess for intubation, mechanical ventilation, and intensive care unit admission
assess for intubation, mechanical ventilation, and intensive care unit admission
Patients who present with signs of life-threatening asthma (e.g., drowsiness, confusion, absence of wheeze [“silent chest”]) should be considered for intubation, mechanical ventilation, and admission to the intensive care unit (ICU).[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
Patients who initially present with a non-life-threatening exacerbation but do not respond adequately to treatment, or who subsequently develop signs of life-threatening asthma, may also require admission to the ICU with consideration for intubation and mechanical ventilation.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
inhaled short-acting beta-2 agonist
Treatment recommended for ALL patients in selected patient group
Repeated administration of an inhaled, short-acting beta-2 agonist (by nebulizer) is the first-line therapy used to rapidly reverse airflow limitation. Treatment should be initiated immediately and titrated based on the patient's response. It should be administered together with inhaled ipratropium (via nebulizer) in severe or life-threatening asthma exacerbations.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report [45]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Nov 2024 [internet publication]. https://www.sign.ac.uk/our-guidelines/british-guideline-on-the-management-of-asthma The combination of a beta-2 agonist and an anticholinergic may produce more improved bronchodilatory effects than either drug alone.[76]Rodrigo G, Rodrigo C, Burschtin O. A meta-analysis of the effects of ipratropium bromide in adults with acute asthma. Am J Med. 1999 Oct;107(4):363-70. http://www.ncbi.nlm.nih.gov/pubmed/10527039?tool=bestpractice.com This combination is also associated with greater improvement in peak flow and forced expiratory volume in 1 second (FEV₁).[77]Rodrigo GJ, Rodrigo C. First-line therapy for adult patients with acute asthma receiving a multiple-dose protocol of ipratropium bromide plus albuterol in the emergency department. Am J Respir Crit Care Med. 2000 Jun;161(6):1862-8. http://www.ncbi.nlm.nih.gov/pubmed/10852758?tool=bestpractice.com [78]Lanes SF, Garrett JE, Wentworth CE 3rd, et al. The effect of adding ipratropium bromide to salbutamol in the treatment of acute asthma: a pooled analysis of three trials. Chest. 1998 Aug;114(2):365-72. http://www.ncbi.nlm.nih.gov/pubmed/9726716?tool=bestpractice.com [79]Plotnick LH, Ducharme FM. Should inhaled anticholinergics be added to beta2 agonists for treating acute childhood and adolescent asthma? A systematic review. BMJ. 1998 Oct 10;317(7164):971-7. http://www.ncbi.nlm.nih.gov/pubmed/9765164?tool=bestpractice.com
The use of nebulizers can transmit respiratory viral particles and potentially contribute to the spread of respiratory viral infections such as COVID-19.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report Consider appropriate level of personal protective equipment (PPE).
Primary options
albuterol inhaled: 2.5 to 5 mg nebulized every 20 minutes for 3 doses, followed by 2.5 to 10 mg every 1-4 hours when required; or 10-15 mg/hour nebulized continuously
OR
levalbuterol inhaled: 1.25 to 2.5 mg nebulized every 20 minutes for 3 doses, followed by 1.25 to 5 mg every 1-4 hours when required
These drug options and doses relate to a patient with no comorbidities.
Primary options
albuterol inhaled: 2.5 to 5 mg nebulized every 20 minutes for 3 doses, followed by 2.5 to 10 mg every 1-4 hours when required; or 10-15 mg/hour nebulized continuously
OR
levalbuterol inhaled: 1.25 to 2.5 mg nebulized every 20 minutes for 3 doses, followed by 1.25 to 5 mg every 1-4 hours when required
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
albuterol inhaled
OR
levalbuterol inhaled
inhaled anticholinergic
Treatment recommended for ALL patients in selected patient group
Inhaled ipratropium should be added to short-acting beta-2 agonists in adults with severe or life-threatening asthma exacerbations.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report [45]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Nov 2024 [internet publication]. https://www.sign.ac.uk/our-guidelines/british-guideline-on-the-management-of-asthma
Anticholinergics, in combination with a beta-2 agonist, may produce more improved bronchodilatory effects than either drug alone.[76]Rodrigo G, Rodrigo C, Burschtin O. A meta-analysis of the effects of ipratropium bromide in adults with acute asthma. Am J Med. 1999 Oct;107(4):363-70. http://www.ncbi.nlm.nih.gov/pubmed/10527039?tool=bestpractice.com This combination is also associated with greater improvement in peak flow and forced expiratory volume in 1 second (FEV₁) and lower hospitalization rates.[77]Rodrigo GJ, Rodrigo C. First-line therapy for adult patients with acute asthma receiving a multiple-dose protocol of ipratropium bromide plus albuterol in the emergency department. Am J Respir Crit Care Med. 2000 Jun;161(6):1862-8. http://www.ncbi.nlm.nih.gov/pubmed/10852758?tool=bestpractice.com [78]Lanes SF, Garrett JE, Wentworth CE 3rd, et al. The effect of adding ipratropium bromide to salbutamol in the treatment of acute asthma: a pooled analysis of three trials. Chest. 1998 Aug;114(2):365-72. http://www.ncbi.nlm.nih.gov/pubmed/9726716?tool=bestpractice.com [79]Plotnick LH, Ducharme FM. Should inhaled anticholinergics be added to beta2 agonists for treating acute childhood and adolescent asthma? A systematic review. BMJ. 1998 Oct 10;317(7164):971-7. http://www.ncbi.nlm.nih.gov/pubmed/9765164?tool=bestpractice.com
Ipratropium should be given only in combination with short-acting beta-2 agonists, not in place of them. Ipratropium may be used in combination with any short-acting beta-2 agonist.
The use of nebulizers can transmit respiratory viral particles and potentially contribute to the spread of respiratory viral infections such as COVID-19.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report Consider appropriate level of personal protective equipment (PPE).
Primary options
ipratropium bromide inhaled: 500 micrograms nebulized given in combination and dosed with each administration of short-acting beta-2 agonist (usually every 20 minutes for 3 doses and then when required)
These drug options and doses relate to a patient with no comorbidities.
Primary options
ipratropium bromide inhaled: 500 micrograms nebulized given in combination and dosed with each administration of short-acting beta-2 agonist (usually every 20 minutes for 3 doses and then when required)
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
ipratropium bromide inhaled
supplemental oxygen
Treatment recommended for ALL patients in selected patient group
Supplemental oxygen should be given by nasal cannula or nonrebreather mask to achieve oxygen saturation of 93% to 95%.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
Oxygen therapy should then be titrated. PaCO₂ may worsen in some patients with severe airflow obstruction on 100% oxygen saturation.
intravenous or oral corticosteroid
Treatment recommended for ALL patients in selected patient group
Systemic corticosteroids have been shown to speed the resolution of exacerbations and prevent relapse.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report [51]Greenberger PA. Clinical aspects of allergic bronchopulmonary aspergillosis. Front Biosci. 2003 Jan 1;8:s119-27. http://www.ncbi.nlm.nih.gov/pubmed/12456338?tool=bestpractice.com
Intravenous corticosteroids can be administered to patients who are unable to take oral medication because they are too dyspneic to swallow, are vomiting, or require noninvasive ventilation or intubation.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report Systemic corticosteroids should ideally be administered within 1 hour of presentation.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
It can take up to 4 hours after corticosteroid administration before clinical improvements are observed.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
International guidelines recommend hydrocortisone as a typical intravenous corticosteroid.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report However, in the US, intravenous methylprednisolone is more typically used in practice. Prednisone is the typical choice when oral therapy is considered suitable. Other oral or intravenous corticosteroids may be used according to your local guidance.
Although guidelines recommend consideration of high-dose inhaled corticosteroids (ICS) for severe exacerbations, in practice they are unlikely to be used in life-threatening exacerbations when the patient is already on a systemic corticosteroid; in adults, evidence of benefit from giving ICS in addition to systemic corticosteroids is conflicting.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report [69]Edmonds ML, Milan SJ, Camargo CA Jr, et al. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database Syst Rev. 2012 Dec 12;(12):CD002308. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002308.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/23235589?tool=bestpractice.com
Treatment course: usually 5-7 days. Tapering not needed if prescribed for less than 2 weeks.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
Primary options
methylprednisolone sodium succinate: 60-80 mg intravenously once daily
OR
hydrocortisone sodium succinate: 200-300 mg/day intravenously given in divided doses every 6-8 hours
Secondary options
prednisone: 40-80 mg/day orally given in 1-2 divided doses
These drug options and doses relate to a patient with no comorbidities.
Primary options
methylprednisolone sodium succinate: 60-80 mg intravenously once daily
OR
hydrocortisone sodium succinate: 200-300 mg/day intravenously given in divided doses every 6-8 hours
Secondary options
prednisone: 40-80 mg/day orally given in 1-2 divided doses
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
methylprednisolone sodium succinate
OR
hydrocortisone sodium succinate
Secondary options
prednisone
supportive care
Treatment recommended for ALL patients in selected patient group
Monitoring and correction of fluid balance and electrolyte disturbances may be needed depending on the patient’s clinical condition (e.g., for patients requiring intravenous rehydration).[45]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Nov 2024 [internet publication]. https://www.sign.ac.uk/our-guidelines/british-guideline-on-the-management-of-asthma
intravenous magnesium
Treatment recommended for SOME patients in selected patient group
Intravenous magnesium sulfate is not recommended for routine use in asthma exacerbations.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report However, a single infusion has been shown to reduce hospital admission rates in certain patients, including adults with a forced expiratory volume in 1 second (FEV₁) <25% to 30% of predicted and those who fail initial treatment.[66]Rowe BH, Bretzlaff JA, Bourdon C, et al. Magnesium sulfate for treating exacerbations of acute asthma in the emergency department. Cochrane Database Syst Rev. 2000 Jan 24;(2):CD001490. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001490/full http://www.ncbi.nlm.nih.gov/pubmed/10796650?tool=bestpractice.com Magnesium is thought to inhibit calcium influx into airway smooth muscle, thereby acting as a bronchodilator.[67]Skobeloff EM, Spivey WH, McNamara RM, et al. Intravenous magnesium sulfate for the treatment of acute asthma in the emergency department. JAMA. 1989 Sep 1;262(9):1210-3. http://www.ncbi.nlm.nih.gov/pubmed/2761061?tool=bestpractice.com The Global Initiative for Asthma recommends that intravenous magnesium sulfate be considered for severe exacerbations that fail to respond to initial treatment.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
Primary options
magnesium sulfate: 2 g intravenously as a single dose given over 20 minutes
These drug options and doses relate to a patient with no comorbidities.
Primary options
magnesium sulfate: 2 g intravenously as a single dose given over 20 minutes
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
magnesium sulfate
antibiotic therapy
Treatment recommended for SOME patients in selected patient group
Antibiotics should not be given routinely in asthma exacerbations unless there is strong evidence of lung infection, such as fever and purulent sputum or radiographic evidence of pneumonia.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report [53]National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program expert panel report 3: guidelines for the diagnosis and management of asthma. Aug 2007 [internet publication]. https://www.ncbi.nlm.nih.gov/books/NBK7232 [72]Normansell R, Sayer B, Waterson S, et al. Antibiotics for exacerbations of asthma. Cochrane Database Syst Rev. 2018 Jun 25;(6):CD002741. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002741.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/29938789?tool=bestpractice.com The majority of acute asthma exacerbations are triggered by viral infection.[8]Singh AM, Busse WW. Asthma exacerbations. 2: aetiology. Thorax. 2006 Sep;61(9):809-16. https://thorax.bmj.com/content/61/9/809.long http://www.ncbi.nlm.nih.gov/pubmed/16936237?tool=bestpractice.com [12]Nicholson KG, Kent J, Ireland DC. Respiratory viruses and exacerbations of asthma in adults. BMJ. 1993 Oct 16;307(6910):982-6. http://www.ncbi.nlm.nih.gov/pubmed/8241910?tool=bestpractice.com [45]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Nov 2024 [internet publication]. https://www.sign.ac.uk/our-guidelines/british-guideline-on-the-management-of-asthma Antibiotic selection and dosing should be according to local resistance patterns.
mechanical ventilation
Treatment recommended for SOME patients in selected patient group
Mechanical ventilation should be given to patients who are refractory to therapy and remain in severe respiratory distress. Ventilatory management strategies often include low respiratory rates, low tidal volumes, high inspiratory flow rates, and avoidance of ventilator-applied positive end-expiratory pressure.
How to insert a tracheal tube in an adult using a laryngoscope.
How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.
severe exacerbation
inhaled short-acting beta-2 agonist
Repeated administration of an inhaled, short-acting beta-2 agonist (by nebulizer or by metered-dose inhaler [MDI] plus spacer) is the first-line therapy used to rapidly reverse airflow limitation. Treatment should be initiated immediately and titrated based on the patient's response. It should be administered with inhaled ipratropium (via nebulizer) in severe or life-threatening asthma exacerbations.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report [45]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Nov 2024 [internet publication]. https://www.sign.ac.uk/our-guidelines/british-guideline-on-the-management-of-asthma The combination of a beta-2 agonist and an anticholinergic may produce more improved bronchodilatory effects than either drug alone.[76]Rodrigo G, Rodrigo C, Burschtin O. A meta-analysis of the effects of ipratropium bromide in adults with acute asthma. Am J Med. 1999 Oct;107(4):363-70. http://www.ncbi.nlm.nih.gov/pubmed/10527039?tool=bestpractice.com This combination is also associated with greater improvement in peak flow and forced expiratory volume in 1 second (FEV₁) and lower hospitalization rates.[77]Rodrigo GJ, Rodrigo C. First-line therapy for adult patients with acute asthma receiving a multiple-dose protocol of ipratropium bromide plus albuterol in the emergency department. Am J Respir Crit Care Med. 2000 Jun;161(6):1862-8. http://www.ncbi.nlm.nih.gov/pubmed/10852758?tool=bestpractice.com [78]Lanes SF, Garrett JE, Wentworth CE 3rd, et al. The effect of adding ipratropium bromide to salbutamol in the treatment of acute asthma: a pooled analysis of three trials. Chest. 1998 Aug;114(2):365-72. http://www.ncbi.nlm.nih.gov/pubmed/9726716?tool=bestpractice.com [79]Plotnick LH, Ducharme FM. Should inhaled anticholinergics be added to beta2 agonists for treating acute childhood and adolescent asthma? A systematic review. BMJ. 1998 Oct 10;317(7164):971-7. http://www.ncbi.nlm.nih.gov/pubmed/9765164?tool=bestpractice.com
Nebulizers are useful if the patient is unable to coordinate use of an MDI.
The use of nebulizers can transmit respiratory viral particles and potentially contribute to the spread of respiratory viral infections such as COVID-19.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report Consider appropriate level of personal protective equipment (PPE).
Primary options
albuterol inhaled: (90 micrograms/dose metered-dose inhaler) 360-720 micrograms (4-8 puffs) every 20 minutes for up to 4 hours, then every 1-4 hours when required; or 2.5 to 5 mg nebulized every 20 minutes for 3 doses, followed by 2.5 to 10 mg every 1-4 hours when required; or 10-15 mg/hour nebulized continuously
OR
levalbuterol inhaled: (45 micrograms/dose metered-dose inhaler) 180-360 micrograms (4-8 puffs) every 20 minutes for up to 4 hours, then every 1-4 hours when required; or 1.25 to 2.5 mg nebulized every 20 minutes for 3 doses, followed by 1.25 to 5 mg every 1-4 hours when required
These drug options and doses relate to a patient with no comorbidities.
Primary options
albuterol inhaled: (90 micrograms/dose metered-dose inhaler) 360-720 micrograms (4-8 puffs) every 20 minutes for up to 4 hours, then every 1-4 hours when required; or 2.5 to 5 mg nebulized every 20 minutes for 3 doses, followed by 2.5 to 10 mg every 1-4 hours when required; or 10-15 mg/hour nebulized continuously
OR
levalbuterol inhaled: (45 micrograms/dose metered-dose inhaler) 180-360 micrograms (4-8 puffs) every 20 minutes for up to 4 hours, then every 1-4 hours when required; or 1.25 to 2.5 mg nebulized every 20 minutes for 3 doses, followed by 1.25 to 5 mg every 1-4 hours when required
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
albuterol inhaled
OR
levalbuterol inhaled
inhaled anticholinergic
Treatment recommended for ALL patients in selected patient group
Inhaled ipratropium should be added to a short-acting beta-2 agonist in adults with severe or life-threatening asthma exacerbations.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report [45]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Nov 2024 [internet publication]. https://www.sign.ac.uk/our-guidelines/british-guideline-on-the-management-of-asthma
Anticholinergics, in combination with a beta-2 agonist, may produce more improved bronchodilatory effects than either drug alone.[76]Rodrigo G, Rodrigo C, Burschtin O. A meta-analysis of the effects of ipratropium bromide in adults with acute asthma. Am J Med. 1999 Oct;107(4):363-70. http://www.ncbi.nlm.nih.gov/pubmed/10527039?tool=bestpractice.com This combination is also associated with greater improvement in peak flow and forced expiratory volume in 1 second (FEV₁) and lower hospitalization rates.[77]Rodrigo GJ, Rodrigo C. First-line therapy for adult patients with acute asthma receiving a multiple-dose protocol of ipratropium bromide plus albuterol in the emergency department. Am J Respir Crit Care Med. 2000 Jun;161(6):1862-8. http://www.ncbi.nlm.nih.gov/pubmed/10852758?tool=bestpractice.com [78]Lanes SF, Garrett JE, Wentworth CE 3rd, et al. The effect of adding ipratropium bromide to salbutamol in the treatment of acute asthma: a pooled analysis of three trials. Chest. 1998 Aug;114(2):365-72. http://www.ncbi.nlm.nih.gov/pubmed/9726716?tool=bestpractice.com [79]Plotnick LH, Ducharme FM. Should inhaled anticholinergics be added to beta2 agonists for treating acute childhood and adolescent asthma? A systematic review. BMJ. 1998 Oct 10;317(7164):971-7. http://www.ncbi.nlm.nih.gov/pubmed/9765164?tool=bestpractice.com
Ipratropium should be given only in combination with short-acting beta-2 agonists, not in place of them. Ipratropium may be used in combination with any short-acting beta-2 agonist.
The use of nebulizers can transmit respiratory viral particles and potentially contribute to the spread of respiratory viral infections such as COVID-19.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report Consider appropriate level of personal protective equipment (PPE).
Primary options
ipratropium bromide inhaled: (17 micrograms/dose metered-dose inhaler) 136 micrograms (8 puffs) every 20 minutes for up to 3 hours given in combination and dosed with each administration of short-acting beta-2 agonist; or 500 micrograms nebulized every 20 minutes for 3 doses and then when required given in combination and dosed with each administration of short-acting beta-2 agonist
These drug options and doses relate to a patient with no comorbidities.
Primary options
ipratropium bromide inhaled: (17 micrograms/dose metered-dose inhaler) 136 micrograms (8 puffs) every 20 minutes for up to 3 hours given in combination and dosed with each administration of short-acting beta-2 agonist; or 500 micrograms nebulized every 20 minutes for 3 doses and then when required given in combination and dosed with each administration of short-acting beta-2 agonist
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
ipratropium bromide inhaled
supplemental oxygen
Treatment recommended for ALL patients in selected patient group
Supplemental oxygen should be given by nasal cannula or nonrebreather mask to achieve oxygen saturation of 93% to 95%.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
Oxygen therapy should then be titrated. PaCO₂ may worsen in some patients with severe airflow obstruction on 100% oxygen saturation.
oral or intravenous corticosteroid
Treatment recommended for ALL patients in selected patient group
Systemic corticosteroids should ideally be administered within 1 hour of presentation.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report It can take up to 4 hours after corticosteroid administration before clinical improvements are observed.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report Some patients may have already started a course of oral corticosteroids if it is part of their self-management plan.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
Systemic corticosteroids have been shown to speed the resolution of exacerbations and prevent relapse.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report [51]Greenberger PA. Clinical aspects of allergic bronchopulmonary aspergillosis. Front Biosci. 2003 Jan 1;8:s119-27. http://www.ncbi.nlm.nih.gov/pubmed/12456338?tool=bestpractice.com Oral administration is the preferred route.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report Intravenous corticosteroids can be administered to patients who are too dyspneic to swallow, are vomiting, or require noninvasive ventilation or intubation.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
Prednisone is the typical choice for oral corticosteroid therapy. International guidelines recommend hydrocortisone as a typical intravenous corticosteroid.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report However, in the US, intravenous methylprednisolone is more typically used in practice. Other oral or intravenous corticosteroids may be used according to your local guidance.
In patients with a severe or life-threatening exacerbation who are receiving systemic corticosteroids, the Global Initiative for Asthma (GINA) guideline recommends consideration of add-on high-dose inhaled corticosteroid (ICS), while also cautioning that evidence of benefit from the combination of a systemic corticosteroid plus ICS is conflicting in adults.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report [69]Edmonds ML, Milan SJ, Camargo CA Jr, et al. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database Syst Rev. 2012 Dec 12;(12):CD002308. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002308.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/23235589?tool=bestpractice.com [70]Kearns N, Maijers I, Harper J, et al. Inhaled corticosteroids in acute asthma: a systemic review and meta-analysis. J Allergy Clin Immunol Pract. 2020 Feb;8(2):605-17. http://www.ncbi.nlm.nih.gov/pubmed/31521830?tool=bestpractice.com In practice, ICS are unlikely to be used if the patient is already on a systemic corticosteroid.
The systemic corticosteroid treatment course is usually 5-7 days. Tapering not needed if prescribed for less than 2 weeks.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report A randomized controlled trial comparing the effects of 2 days of oral dexamethasone and 5 days of oral prednisone in patients ages 18-45 years with acute asthma exacerbations (peak expiratory flow rate <80% of ideal) showed that the former is at least as effective as the latter in returning patients to their normal level of activity and preventing relapse.[71]Kravitz J, Dominici P, Ufberg J, et al. Two days of dexamethasone versus 5 days of prednisone in the treatment of acute asthma: a randomized controlled trial. Ann Emerg Med. 2011 Aug;58(2):200-4. http://www.ncbi.nlm.nih.gov/pubmed/21334098?tool=bestpractice.com GINA advises that, if used, oral dexamethasone should not be continued for more than 2 days due to concerns about metabolic adverse effects: if further systemic corticosteroid treatment is needed, a switch to prednisone should be considered.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
Primary options
prednisone: 40-80 mg/day orally given in 1-2 divided doses
Secondary options
methylprednisolone sodium succinate: 60-80 mg intravenously once daily
OR
hydrocortisone sodium succinate: 200-300 mg/day intravenously given in divided doses every 6-8 hours
These drug options and doses relate to a patient with no comorbidities.
Primary options
prednisone: 40-80 mg/day orally given in 1-2 divided doses
Secondary options
methylprednisolone sodium succinate: 60-80 mg intravenously once daily
OR
hydrocortisone sodium succinate: 200-300 mg/day intravenously given in divided doses every 6-8 hours
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
prednisone
Secondary options
methylprednisolone sodium succinate
OR
hydrocortisone sodium succinate
supportive care
Treatment recommended for ALL patients in selected patient group
Monitoring and correction of fluid balance and electrolyte disturbances may be needed depending on the patient’s clinical condition (e.g., for patients requiring intravenous rehydration).[45]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Nov 2024 [internet publication]. https://www.sign.ac.uk/our-guidelines/british-guideline-on-the-management-of-asthma
intravenous magnesium
Treatment recommended for SOME patients in selected patient group
Intravenous magnesium sulfate is not recommended for routine use in asthma exacerbations.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report However, a single infusion has been shown to reduce hospital admission rates in certain patients, including adults with a forced expiratory volume in 1 second (FEV₁) <25% to 30% of predicted and those who fail initial treatment.[66]Rowe BH, Bretzlaff JA, Bourdon C, et al. Magnesium sulfate for treating exacerbations of acute asthma in the emergency department. Cochrane Database Syst Rev. 2000 Jan 24;(2):CD001490. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001490/full http://www.ncbi.nlm.nih.gov/pubmed/10796650?tool=bestpractice.com
Magnesium is thought to inhibit calcium influx into airway smooth muscle, thereby acting as a bronchodilator.[67]Skobeloff EM, Spivey WH, McNamara RM, et al. Intravenous magnesium sulfate for the treatment of acute asthma in the emergency department. JAMA. 1989 Sep 1;262(9):1210-3. http://www.ncbi.nlm.nih.gov/pubmed/2761061?tool=bestpractice.com The Global Initiative for Asthma recommends that intravenous magnesium sulfate be considered for severe exacerbations that fail to respond to initial treatment.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
Primary options
magnesium sulfate: 2 g intravenously as a single dose given over 20 minutes
These drug options and doses relate to a patient with no comorbidities.
Primary options
magnesium sulfate: 2 g intravenously as a single dose given over 20 minutes
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
magnesium sulfate
antibiotic therapy
Treatment recommended for SOME patients in selected patient group
Antibiotics should not be given routinely in asthma exacerbations unless there is strong evidence of lung infection, such as fever and purulent sputum or radiographic evidence of pneumonia.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report [53]National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program expert panel report 3: guidelines for the diagnosis and management of asthma. Aug 2007 [internet publication]. https://www.ncbi.nlm.nih.gov/books/NBK7232 [72]Normansell R, Sayer B, Waterson S, et al. Antibiotics for exacerbations of asthma. Cochrane Database Syst Rev. 2018 Jun 25;(6):CD002741. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002741.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/29938789?tool=bestpractice.com The majority of acute asthma exacerbations are triggered by viral infection.[8]Singh AM, Busse WW. Asthma exacerbations. 2: aetiology. Thorax. 2006 Sep;61(9):809-16. https://thorax.bmj.com/content/61/9/809.long http://www.ncbi.nlm.nih.gov/pubmed/16936237?tool=bestpractice.com [12]Nicholson KG, Kent J, Ireland DC. Respiratory viruses and exacerbations of asthma in adults. BMJ. 1993 Oct 16;307(6910):982-6. http://www.ncbi.nlm.nih.gov/pubmed/8241910?tool=bestpractice.com [45]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Nov 2024 [internet publication]. https://www.sign.ac.uk/our-guidelines/british-guideline-on-the-management-of-asthma Antibiotic selection and dosing should be according to local resistance patterns.
mild to moderate exacerbation
inhaled short-acting beta-2 agonist
Repeated administration of an inhaled, short-acting beta-2 agonist (by metered-dose inhaler [MDI] or nebulizer) is the first-line therapy used to rapidly reverse airflow limitation. Treatment should be initiated immediately and titrated based on the patient's response.
For patients with mild to moderate exacerbations, delivery of a short-acting beta-2 agonist via an MDI plus spacer or a dry powder inhaler leads to similar improvements in lung function as delivery via nebulizer.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report Nebulizers are useful if the patient is unable to coordinate use of an MDI.
The use of nebulizers can transmit respiratory viral particles and potentially contribute to the spread of respiratory viral infections such as COVID-19.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report Consider appropriate level of personal protective equipment (PPE).
Primary options
albuterol inhaled: (90 micrograms/dose metered-dose inhaler) 360-720 micrograms (4-8 puffs) every 20 minutes for up to 4 hours, then every 1-4 hours when required; or 2.5 to 5 mg nebulized every 20 minutes for 3 doses, followed by 2.5 to 10 mg every 1-4 hours when required; or 10-15 mg/hour nebulized continuously
OR
levalbuterol inhaled: (45 micrograms/dose metered-dose inhaler) 180-360 micrograms (4-8 puffs) every 20 minutes for up to 4 hours, then every 1-4 hours when required; or 1.25 to 2.5 mg nebulized every 20 minutes for 3 doses, followed by 1.25 to 5 mg every 1-4 hours when required
These drug options and doses relate to a patient with no comorbidities.
Primary options
albuterol inhaled: (90 micrograms/dose metered-dose inhaler) 360-720 micrograms (4-8 puffs) every 20 minutes for up to 4 hours, then every 1-4 hours when required; or 2.5 to 5 mg nebulized every 20 minutes for 3 doses, followed by 2.5 to 10 mg every 1-4 hours when required; or 10-15 mg/hour nebulized continuously
OR
levalbuterol inhaled: (45 micrograms/dose metered-dose inhaler) 180-360 micrograms (4-8 puffs) every 20 minutes for up to 4 hours, then every 1-4 hours when required; or 1.25 to 2.5 mg nebulized every 20 minutes for 3 doses, followed by 1.25 to 5 mg every 1-4 hours when required
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
albuterol inhaled
OR
levalbuterol inhaled
oral corticosteroid
Treatment recommended for ALL patients in selected patient group
A short course of an oral corticosteroid (e.g., prednisone) should be given.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report It can take up to 4 hours after corticosteroid administration before clinical improvements are observed.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report Some patients may have already started a course of oral corticosteroids if it is part of their self-management plan.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
Systemic corticosteroids have been shown to speed the resolution of exacerbations and prevent relapse.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report [51]Greenberger PA. Clinical aspects of allergic bronchopulmonary aspergillosis. Front Biosci. 2003 Jan 1;8:s119-27. http://www.ncbi.nlm.nih.gov/pubmed/12456338?tool=bestpractice.com In acute care settings, the Global Initiative for Asthma (GINA) advises that systemic corticosteroids should be given in all but the mildest exacerbations; their use is especially important if short-acting beta-2 agonist treatment does not achieve lasting symptom improvement, or if the patient has a history of exacerbations requiring oral corticosteroids or was using these when the present exacerbation occurred.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
A randomized controlled trial comparing the effects of 2 days of oral dexamethasone and 5 days of oral prednisone in patients ages 18-45 years with acute asthma exacerbations (peak expiratory flow rate <80% of ideal) showed that the former is at least as effective as the latter in returning patients to their normal level of activity and preventing relapse.[71]Kravitz J, Dominici P, Ufberg J, et al. Two days of dexamethasone versus 5 days of prednisone in the treatment of acute asthma: a randomized controlled trial. Ann Emerg Med. 2011 Aug;58(2):200-4. http://www.ncbi.nlm.nih.gov/pubmed/21334098?tool=bestpractice.com GINA advises that, if used, oral dexamethasone should not be continued for more than 2 days due to concerns about metabolic adverse effects: if further systemic corticosteroid treatment is needed, a switch to prednisone should be considered.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
Treatment course: at least 5 days and until recovery from acute exacerbation; this course does not need tapering before cessation.
Primary options
prednisone: 40-80 mg/day orally given in 1-2 divided doses
These drug options and doses relate to a patient with no comorbidities.
Primary options
prednisone: 40-80 mg/day orally given in 1-2 divided doses
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
prednisone
inhaled anticholinergic
Treatment recommended for SOME patients in selected patient group
Inhaled ipratropium can be added to a short-acting beta-2 agonist in adults with moderate asthma exacerbations, particularly if there is a poor response to initial treatment.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report [45]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Nov 2024 [internet publication]. https://www.sign.ac.uk/our-guidelines/british-guideline-on-the-management-of-asthma
Anticholinergics, in combination with a beta-2 agonist, may produce more improved bronchodilatory effects than either drug alone.[76]Rodrigo G, Rodrigo C, Burschtin O. A meta-analysis of the effects of ipratropium bromide in adults with acute asthma. Am J Med. 1999 Oct;107(4):363-70. http://www.ncbi.nlm.nih.gov/pubmed/10527039?tool=bestpractice.com This combination is also associated with greater improvement in peak flow and forced expiratory volume in 1 second (FEV₁) and lower hospitalization rates.[77]Rodrigo GJ, Rodrigo C. First-line therapy for adult patients with acute asthma receiving a multiple-dose protocol of ipratropium bromide plus albuterol in the emergency department. Am J Respir Crit Care Med. 2000 Jun;161(6):1862-8. http://www.ncbi.nlm.nih.gov/pubmed/10852758?tool=bestpractice.com [78]Lanes SF, Garrett JE, Wentworth CE 3rd, et al. The effect of adding ipratropium bromide to salbutamol in the treatment of acute asthma: a pooled analysis of three trials. Chest. 1998 Aug;114(2):365-72. http://www.ncbi.nlm.nih.gov/pubmed/9726716?tool=bestpractice.com [79]Plotnick LH, Ducharme FM. Should inhaled anticholinergics be added to beta2 agonists for treating acute childhood and adolescent asthma? A systematic review. BMJ. 1998 Oct 10;317(7164):971-7. http://www.ncbi.nlm.nih.gov/pubmed/9765164?tool=bestpractice.com
Ipratropium should be given only in combination with short-acting beta-2 agonists, not in place of them. Ipratropium may be used in combination with any short-acting beta-2 agonist.
The use of nebulizers can transmit respiratory viral particles and potentially contribute to the spread of respiratory viral infections such as COVID-19.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report Consider appropriate level of personal protective equipment (PPE).
Primary options
ipratropium bromide inhaled: (17 micrograms/dose metered-dose inhaler) 136 micrograms (8 puffs) every 20 minutes for up to 3 hours given in combination and dosed with each administration of short-acting beta-2 agonist; or 500 micrograms nebulized every 20 minutes for 3 doses and then when required given in combination and dosed with each administration of short-acting beta-2 agonist
These drug options and doses relate to a patient with no comorbidities.
Primary options
ipratropium bromide inhaled: (17 micrograms/dose metered-dose inhaler) 136 micrograms (8 puffs) every 20 minutes for up to 3 hours given in combination and dosed with each administration of short-acting beta-2 agonist; or 500 micrograms nebulized every 20 minutes for 3 doses and then when required given in combination and dosed with each administration of short-acting beta-2 agonist
Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.
Show drug information for a patient with no comorbidities
Primary options
ipratropium bromide inhaled
supplemental oxygen
Treatment recommended for SOME patients in selected patient group
Supplemental oxygen should be given, if necessary, by nasal cannula or nonrebreather mask to achieve oxygen saturation of 93% to 95%.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
Oxygen therapy should then be titrated. PaCO₂ may worsen in some patients with severe airflow obstruction on 100% oxygen saturation.
antibiotic therapy
Treatment recommended for SOME patients in selected patient group
Antibiotics should not be given routinely in asthma exacerbations unless there is strong evidence of lung infection, such as fever and purulent sputum or radiographic evidence of pneumonia.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report [53]National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program expert panel report 3: guidelines for the diagnosis and management of asthma. Aug 2007 [internet publication]. https://www.ncbi.nlm.nih.gov/books/NBK7232 [72]Normansell R, Sayer B, Waterson S, et al. Antibiotics for exacerbations of asthma. Cochrane Database Syst Rev. 2018 Jun 25;(6):CD002741. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002741.pub2/full http://www.ncbi.nlm.nih.gov/pubmed/29938789?tool=bestpractice.com The majority of acute asthma exacerbations are triggered by viral infection.[8]Singh AM, Busse WW. Asthma exacerbations. 2: aetiology. Thorax. 2006 Sep;61(9):809-16. https://thorax.bmj.com/content/61/9/809.long http://www.ncbi.nlm.nih.gov/pubmed/16936237?tool=bestpractice.com [12]Nicholson KG, Kent J, Ireland DC. Respiratory viruses and exacerbations of asthma in adults. BMJ. 1993 Oct 16;307(6910):982-6. http://www.ncbi.nlm.nih.gov/pubmed/8241910?tool=bestpractice.com [45]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Nov 2024 [internet publication]. https://www.sign.ac.uk/our-guidelines/british-guideline-on-the-management-of-asthma Antibiotic selection and dosing should be according to local resistance patterns.
symptomatic asthma
subsequent therapy
Prior to discharge, inhaled corticosteroid-based controller therapy should be initiated, if not previously prescribed.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report Patients already taking inhaled corticosteroid-containing medication should generally have their treatment stepped up for 2-4 weeks.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report If the exacerbation occurred on a background of long-term poor asthma control (despite good adherence and inhaler technique) a longer-term step up (e.g., 2-3 months) may be indicated.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report The Global Initiative for Asthma (GINA) recommends a step up or switch to maintenance-and-reliever-therapy (MART) with inhaled corticosteroid (ICS)-formoterol (“Track 1” approach) following an exacerbation, and advises that Step 4 MART is appropriate if the patient visited the emergency department or was hospitalized.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
Patients should resume their normal reliever inhaler before discharge if this was replaced with a short-acting beta-2 agonist reliever during acute treatment of the exacerbation.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report They should be transitioned back to as-needed rather than regular use of reliever medication, based on symptomatic and objective improvement.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report GINA recommends considering a switch to a treatment regimen with an ICS-formoterol reliever for those who were using a short-acting beta-2 agonist reliever before the exacerbation, to reduce their risk of future exacerbations.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
Adherence and inhaler technique should be reassessed before discharge.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report Patients should be followed up by a primary physician or pulmonologist within 2-7 days after an exacerbation (or within 1-2 weeks if the exacerbation was self-managed at home) to assess and optimize their asthma management, including medications, review of modifiable risk factors and comorbidities, inhaler technique, and written asthma action plan.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
Guidelines recommend that asthma severity and control be viewed as a ladder in which medication can be stepped up or stepped down based on the severity of the disease and adequacy of the control.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
The stepwise approach is meant to assist, not replace, the clinical decision-making required to meet individual patient needs.
Patients may start at any step of the ladder, and medications can be added (stepped up) if needed. Increasing use of short-acting beta-agonist or use >2 days a week for symptom relief (not prevention of exercise-induced bronchospasm) generally indicates inadequate control and the need to step up treatment.
Patient's asthma control should be regularly assessed with the aim of stepping down the ladder if disease has been well controlled for at least 3 months. A step-down may increase the risk for exacerbations, and steps should be taken to reduce the risk (e.g., avoid stepping down too far/quickly or at times of increased exacerbation risk).[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report A written action plan should be in place detailing how and when to step treatment back up if asthma control worsens (ensuring the necessary medications are available to the patient to follow this plan).[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report Close monitoring during step-down (especially in patients with risk factors for exacerbations) and scheduled follow-up is advised to evaluate response.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report ICS-containing medication should not be completely withdrawn, and adherence with this during the step-down should be encouraged.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication]. https://ginasthma.org/2024-report
There is insufficient evidence to recommend universal use of sputum eosinophils or fractional exhaled nitric oxide (FeNO) levels to tailor asthma therapy. However, some evidence suggests this approach may decrease frequency of asthma exacerbations.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication].
https://ginasthma.org/2024-report
[74]Petsky HL, Li A, Chang AB. Tailored interventions based on sputum eosinophils versus clinical symptoms for asthma in children and adults. Cochrane Database Syst Rev. 2017 Aug 24;(8):CD005603.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005603.pub3/full
http://www.ncbi.nlm.nih.gov/pubmed/28837221?tool=bestpractice.com
[75]Petsky HL, Kew KM, Turner C, Chang AB. Exhaled nitric oxide levels to guide treatment for adults with asthma. Cochrane Database Syst Rev. 2016 Sep 1;(9):CD011440.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011440.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/27580628?tool=bestpractice.com
[ 
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What are the effects of using fractional exhaled nitric oxide (FeNO) levels to guide treatment for adults with asthma?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2107/fullShow me the answer GINA recommends sputum-guided treatment for adults with moderate or severe asthma who are managed in (or can be referred to) a center offering this.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication].
https://ginasthma.org/2024-report
FeNO measurement may be considered as part of an ongoing monitoring and management strategy for selected patients, if there is persisting uncertainty in choosing, monitoring, or adjusting therapies.[39]Cloutier MM, Baptist AP, Teach SJ, et al; Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC). 2020 focused updates to the asthma management guidelines: a report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020 Dec;146(6):1217-70.
https://www.jacionline.org/article/S0091-6749(20)31404-4/fulltext
http://www.ncbi.nlm.nih.gov/pubmed/33280709?tool=bestpractice.com
In clinical practice, FeNO is mainly used to help guide treatment decisions in those with severe asthma.[1]Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. May 2024 [internet publication].
https://ginasthma.org/2024-report
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