Reference — Pulmonary Diseases
Asthma Stepwise Management
GINA stepwise therapy at a glance — the two reliever tracks across steps 1–5, what each controller and reliever class does, and the pharmacology of an acute exacerbation, with the RT notes that matter at the bedside.
Written by Apex Respiratory Editorial Team
Educational use only. This material supports respiratory therapy education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional protocols, or physician orders. Always follow facility policies and current provider orders, and verify calculations independently before clinical use.
Overview
GINA frames asthma treatment as a control-based cycle — assess, adjust, review — stepped up or down to the lowest therapy that keeps symptoms and exacerbation risk controlled. The defining modern change is that every step now contains an inhaled corticosteroid: short-acting beta-agonist–only treatment is no longer recommended because it leaves the underlying inflammation untreated. Two pathways exist — the preferred Track 1, which uses ICS-formoterol as both maintenance and reliever, and Track 2, which pairs a SABA reliever with separate maintenance ICS.
GINA Stepwise Therapy (Adults & Adolescents)
| Step | Track 1 — preferred (ICS-formoterol reliever) | Track 2 — alternative (SABA reliever) |
|---|---|---|
| Step 1 | As-needed low-dose ICS-formoterol | Low-dose ICS taken whenever a SABA is used |
| Step 2 | As-needed low-dose ICS-formoterol | Daily low-dose ICS + as-needed SABA |
| Step 3 | Low-dose ICS-formoterol maintenance + reliever (MART) | Low-dose ICS-LABA + as-needed SABA |
| Step 4 | Medium-dose ICS-formoterol maintenance + reliever (MART) | Medium/high-dose ICS-LABA + as-needed SABA |
| Step 5 | High-dose ICS-formoterol; add LAMA; refer for phenotyping ± biologic | High-dose ICS-LABA + LAMA ± biologic + as-needed SABA |
MART = maintenance and reliever therapy: the same ICS-formoterol inhaler is used for daily control and for symptom relief. A SABA reliever (Track 2) is only appropriate alongside a maintenance ICS.
Controllers & Relievers by Class
| Class | Role | Key RT Notes |
|---|---|---|
| ICS | Controller — cornerstone anti-inflammatory | Rinse mouth after use; full effect builds over days to weeks. |
| ICS-formoterol | Controller + anti-inflammatory reliever (MART) | Single inhaler used for both maintenance and relief in the Track 1 pathway. |
| LABA | Add-on bronchodilator | Never used as monotherapy in asthma — only in a fixed combination with an ICS. |
| LAMA (tiotropium) | Add-on at Steps 4–5 | For asthma still uncontrolled on ICS-LABA. |
| SABA | Reliever (Track 2) | Reliever only; SABA-only treatment is no longer recommended. |
| Systemic corticosteroids (OCS) | Exacerbations and severe disease | Short courses for flares; minimize chronic exposure. |
| Biologics (anti-IgE, anti-IL5/5R, anti-IL4Rα) | Severe phenotype-targeted therapy | Specialist-initiated for severe eosinophilic or allergic asthma. |
Acute Exacerbation Pharmacology
| Intervention | Detail |
|---|---|
| Repetitive SABA | Albuterol by nebulizer or MDI with spacer; add ipratropium (SAMA) in severe exacerbations. |
| Early systemic corticosteroids | Oral prednisolone within the first hour of a moderate-to-severe flare; use IV when the patient cannot take it orally. |
| Controlled oxygen | Titrate to SpO₂ 93–95% in adults; avoid routine high-flow oxygen. |
| Magnesium sulfate IV | A single dose for severe exacerbations not responding to initial bronchodilator and steroid therapy. |
| Escalation | Worsening despite therapy prompts NIV/ICU consideration; a silent chest, exhaustion, or a rising PaCO₂ are ominous signs. |
Clinical Notes
- Every step contains an ICS. The central GINA shift is that anti-inflammatory treatment is present at all steps; relieving bronchospasm with a SABA alone leaves the inflammation that drives exacerbations untreated.
- Never give a LABA as monotherapy. Long-acting beta-agonists used alone in asthma are linked to worse outcomes; they appear only in fixed ICS-LABA combinations.
- SABA overuse is a risk flag. Dispensing of three or more reliever canisters a year signals poor control and a higher exacerbation and mortality risk — reassess rather than simply refill.
- Check technique, adherence, and triggers before stepping up. Most “uncontrolled” asthma is a device or adherence problem, not true treatment failure.
- A normalizing PaCO₂ in an acute attack is ominous. Early in a severe exacerbation the patient hyperventilates and PaCO₂ falls; a rising or “normal” PaCO₂ can signal fatigue and impending respiratory failure, not improvement.
Related Resources
Sources
- Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention (current annual report). GINA.
- Kacmarek RM, Stoller JK, Heuer AJ. Egan's Fundamentals of Respiratory Care. 12th ed. Elsevier; 2021. Asthma and aerosol drug therapy chapters.
- Gardenhire DS. Rau's Respiratory Care Pharmacology. 10th ed. Elsevier; 2019.