Bronchial Asthma — Management Guideline
Source: Global Initiative for Asthma (GINA), 2024 Global Strategy Report
Guideline: Strong
Guideline: Conditional
Guideline: Not recommended
ClinicoQ pathway suggestion (not from the cited guideline)
Diagnosis
Diagnostic criteria
Supported by a history of variable respiratory symptoms plus documented variable expiratory airflow limitation (e.g., ≥12% and 200 mL increase in FEV1 after bronchodilator) on spirometry or peak flow monitoring.
⚠ Alarm features (investigate before diagnosing)
- Sudden severe breathlessness with cyanosis or a silent chest (impending respiratory failure)
- Poor response to reliever inhaler during an acute exacerbation
- Signs suggesting an alternative diagnosis: unilateral wheeze, clubbing, significant weight loss, hemoptysis
Initial workup
| Test | When to order |
|---|---|
| Spirometry with bronchodilator reversibility | At initial diagnosis, in all patients able to perform the test. |
| Peak expiratory flow (PEF) diary | When spirometry is unavailable or the diagnosis is uncertain. |
| Inhaler technique and adherence check | Before escalating therapy for poor control. |
Treatment
Steps 1–2 (mild, infrequent symptoms)
1
As-needed low-dose ICS-formoterol (e.g., budesonide-formoterol 200/6 mcg)
Strong (Guideline recommendation) — preferred over SABA-only reliever at any severity
- Dose
- 1 inhalation as needed for symptoms; no separate maintenance dosing
- Duration
- Ongoing, reassess control regularly
- Evidence level
- High
- Avoid if
- Known hypersensitivity to formoterol or budesonide
- If no response ClinicoQ pathway
- Move to Step 3 (maintenance ICS-formoterol)
Step 3 (more frequent symptoms)
1
Maintenance and reliever therapy (MART): low-dose ICS-formoterol maintenance plus as-needed for relief
Strong (Guideline recommendation) — preferred over separate ICS + SABA reliever
- Dose
- 1 inhalation twice daily maintenance, plus 1 as-needed for symptoms
- Duration
- Ongoing, reassess at 2–3 months
- Evidence level
- High
- Avoid if
- Same hypersensitivity precaution as above
- If no response ClinicoQ pathway
- Increase to medium-dose MART (Step 4) after checking technique and adherence
Steps 4–5 (persistent symptoms despite Step 3)
1
Medium-dose ICS-formoterol MART
Strong (Guideline recommendation)
- Dose
- Increase maintenance inhalations (e.g., 2 inhalations twice daily plus as-needed)
- Duration
- Ongoing, reassess at 2–3 months
- Evidence level
- Moderate
- Avoid if
- Same as above
- If no response ClinicoQ pathway
- Refer for specialist assessment, phenotyping, and possible add-on biologic therapy
2
Referral for specialist assessment (severe asthma phenotyping, biologic candidacy)
Strong (Guideline recommendation)
- Dose
- —
- Duration
- —
- Evidence level
- Moderate
- Avoid if
- —
- If no response
- —
✕ Treatments the guideline advises against
SABA as sole/monotherapy at any severity: Guideline explicitly recommends against this since 2019 — SABA-only use increases risk of severe exacerbations and death.
Oral salbutamol or oral theophylline: Guideline does not recommend either agent.
⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.