Submodule
Definition, Diagnosis, and Phenotype
Asthma combines variable respiratory symptoms with variable expiratory airflow. Inflammation, hyperresponsiveness, bronchoconstriction, mucus, and remodeling vary across patients and over time.
- Variable symptoms
- Variable airflow
- Bronchodilator response
- Differential diagnosis
- Type 2 phenotype
Wheeze, dyspnea, tightness, or cough change over time
Spirometry, peak flow, treatment response, or challenge
Type 2 signals, exposure, occupation, and competing disease
Require two kinds of evidence
Asthma presents with wheeze, shortness of breath, chest tightness, or cough that vary in frequency and intensity. Confirm variable expiratory airflow with spirometry before and after bronchodilator, peak-flow variability, response to inhaled corticosteroid treatment, or bronchial challenge when needed. More than one test may be required.
Test before treatment when possible
Objective confirmation becomes harder after inhaled corticosteroids improve variability. In urgent disease, treat immediately and confirm later. Record baseline FEV1, FVC, ratio, bronchodilator timing, medication withholding, effort, and test quality. A normal test on a good day does not exclude asthma.
Challenge the diagnosis
Consider inducible laryngeal obstruction, COPD, heart failure, dysfunctional breathing, reflux, upper-airway cough, bronchiectasis, infection, pulmonary embolism, obesity, foreign body, medication effect, and deconditioning. Isolated cough has a broad differential, and wheeze is not specific.
Describe treatable traits
Type 2 inflammation may be supported by blood eosinophils, FeNO, allergy, nasal polyps, or steroid response, but biomarkers vary with treatment, smoking, infection, and comorbidity. Low markers do not exclude asthma. Occupational pattern, obesity, aspirin-exacerbated disease, exercise, and allergic exposure can define additional traits.
Quick check
Submodule
Control, Risk, and Longitudinal Assessment
Few symptoms do not guarantee low risk. Every review should measure current impairment, future exacerbation and mortality risk, lung function, treatment exposure, and the patient's goals.
- Symptom control
- Exacerbation risk
- SABA exposure
- Lung function
- Adherence and technique
Day, night, activity, and reliever use over four weeks
Prior attacks, low airflow, SABA exposure, and inadequate ICS
Access, adherence, technique, exposure, and comorbidity
Separate control from risk
Assess daytime symptoms, night waking, reliever use, and activity limitation over the previous four weeks. Separately assess prior severe exacerbation, low FEV1, excess SABA exposure, no or inadequate ICS, smoking or vaping, allergens, eosinophilia, pregnancy, obesity, psychosocial stress, poor access, and medication adverse effects.
Treat an exacerbation as a sentinel event
An emergency visit, hospitalization, systemic corticosteroid course, intubation, or near-fatal event predicts future risk even if current symptoms are sparse. Review the trigger, treatment, discharge medicines, access, action plan, and follow-up. Do not simply restore the preattack regimen without explaining failure.
Measure implementation
Ask in a nonjudgmental way how often medicines are missed, inspect refill history when available, and watch the patient use every inhaler. Check inspiratory flow for dry-powder devices, coordination for metered-dose inhalers, spacer use, priming, cleaning, dose counter, storage, and affordability.
Step up and down as therapeutic trials
Before stepping up, confirm diagnosis, adherence, technique, exposure, and comorbidity. Document a target and follow-up. When control and lung function remain stable for at least about three months, consider reducing ICS exposure gradually, often by 25 to 50 percent at intervals, but do not completely stop ICS in adults or adolescents.
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Submodule
Airway Pharmacology and Inhaler Delivery
Relief and risk reduction come from different but complementary mechanisms. Molecule, onset, duration, device, particle delivery, and the patient's technique determine the actual dose at the airway.
- Beta2 agonism
- Inhaled corticosteroids
- LABA safety
- LAMA and leukotrienes
- Device matching
Rapid cyclic AMP signaling reverses bronchoconstriction
Repeated airway exposure suppresses inflammatory signaling
Flow, coordination, spacer, access, and preference shape dose
Relax airway smooth muscle
Beta2 agonists increase intracellular cyclic AMP in airway smooth muscle and rapidly reverse bronchoconstriction. Albuterol is short acting. Formoterol has rapid onset with long duration, permitting selected anti-inflammatory reliever and maintenance-and-reliever strategies when combined with ICS. Other LABAs with slower onset are not substitutes for formoterol reliever regimens.
Suppress airway inflammation
Inhaled corticosteroids alter gene transcription, reduce inflammatory cells and mediators, improve hyperresponsiveness, and lower exacerbation and death risk. Benefit depends on repeated airway exposure. Rinse and spit after maintenance doses when appropriate, use a spacer with compatible metered-dose ICS, and monitor dysphonia, candidiasis, growth, bone, eye, adrenal, and interaction risk according to dose and duration.
Never use LABA alone in asthma
LABA monotherapy increases serious asthma risk. Pair LABA with ICS. LAMA can modestly improve lung function and exacerbation outcomes as add-on therapy in selected uncontrolled disease. Leukotriene receptor antagonists are generally less effective than ICS and require attention to montelukast's serious neuropsychiatric warning.
Match the device to the person
Pressurized metered-dose, breath-actuated, dry-powder, soft-mist, nebulized, and spacer systems require different coordination and inspiratory flow. Choose around age, dexterity, cognition, inspiratory ability, preference, portability, cost, environmental impact, and the ability to demonstrate reliable use.
Quick check
Submodule
Stepwise Controller and Reliever Strategy
Every patient needs inhaled corticosteroid exposure. GINA Track 1 uses low-dose ICS-formoterol as the adult and adolescent reliever across steps, while Track 2 uses an ICS-containing alternative when Track 1 is unavailable or unsuitable.
- AIR-only
- MART
- Track 2
- ICS-SABA
- US-label distinction
AIR-only for Steps 1 and 2, MART for Steps 3 through 5
ICS-SABA or daily ICS-containing control plus reliever
Match evidence to product, age, device, jurisdiction, and limit
Prefer anti-inflammatory relief
GINA 2026 Track 1 prefers low-dose ICS-formoterol for relief in adults and adolescents because it reduces severe exacerbations compared with SABA-reliever regimens. Steps 1 and 2 use as-needed AIR-only therapy. Steps 3 through 5 use maintenance ICS-formoterol plus the same inhaler as needed, called MART.
Use Track 2 when it fits better
Track 2 includes an ICS-containing reliever strategy or daily ICS-containing controller plus reliever. GINA 2026 adds as-needed low-dose ICS-SABA as an adult and adolescent Step 1 alternative. FDA-labeled albuterol-budesonide is an as-needed rescue product for adults and is not maintenance therapy. If separate ICS and SABA inhalers are used, adherence to taking ICS whenever SABA is used is critical.
Keep guideline and label distinct
GINA is an international evidence strategy. US labels define approved product use. Current US budesonide-formoterol maintenance labels state that the product is not a rescue inhaler, although GINA supports ICS-formoterol AIR and MART using evidence-based formulations. Clinicians must apply local regulation, formulary, product strength, device, age, and maximum inhalation instructions.
Escalate only after fundamentals
For persistent uncontrolled disease, verify exposure and implementation, then progress from low-dose to medium-dose ICS-formoterol MART or an alternative ICS-LABA strategy. Add LAMA or refer for phenotype assessment at higher steps rather than repeatedly increasing SABA or oral corticosteroid exposure.
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Submodule
Children, Special Situations, and Severe Asthma
Age, pregnancy, exercise, occupation, aspirin sensitivity, and phenotype alter treatment. Severe asthma is a retrospective diagnosis after high-dose optimized care still fails or is required to maintain control.
- Children 6 to 11
- Preschool wheeze
- Pregnancy and exercise
- Difficult-to-treat asthma
- Biologic phenotype
Diagnosis, technique, adherence, access, exposure, and comorbidity
Allergy, eosinophils, FeNO, polyps, dermatitis, and steroid burden
IgE, IL-5, IL-4R alpha, or TSLP with response audit
Use age-specific pathways
Children 6 to 11 should not receive SABA-only treatment. Regimens include ICS whenever reliever is used, daily low-dose ICS, and at higher steps selected ICS-LABA or very-low-dose to low-dose ICS-formoterol MART according to GINA, local approval, and device ability. Preschool recurrent wheeze requires probability-based diagnosis, trigger pattern, response, and frequent reassessment.
Treat pregnancy and exercise without withholding control
Continue effective ICS-containing treatment during pregnancy because exacerbations and hypoxemia threaten both parent and fetus. Monitor more frequently. ICS-formoterol can be used before exercise in the relevant strategy, or a reliever can be taken before activity, while persistent exercise symptoms trigger review of baseline control and differential diagnosis.
Fix difficult-to-treat asthma first
Before severe-asthma labeling, reconfirm diagnosis, inhaler technique, adherence, access, smoking and vaping, occupational exposure, allergens, obesity, rhinosinusitis and polyps, reflux, sleep apnea, mental health, medication triggers, and treatment intensity. Distinguish uncontrolled disease from true treatment resistance.
Match biologic to phenotype and label
Omalizumab targets IgE-mediated allergic asthma. Anti-IL-5 or IL-5 receptor therapies target eosinophilic disease. Dupilumab blocks IL-4 receptor alpha signaling in Type 2 disease, and tezepelumab targets upstream TSLP with broader eligibility. Product age, biomarkers, exacerbations, steroid dependence, comorbid polyps or dermatitis, dosing, response, adverse effects, payer rules, and current labels determine selection.
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Submodule
Acute Exacerbations, Action Plans, and Follow-Up
An exacerbation is acute or subacute worsening in symptoms and lung function. Treatment restores oxygenation and airflow, suppresses inflammation, identifies life threats, and closes the prevention loop.
- Severity assessment
- Bronchodilator and ICS
- Systemic corticosteroid
- Anaphylaxis
- Discharge and action plan
Speech, effort, oxygen, airflow, mental status, and quiet chest
Rapid bronchodilator, selected ipratropium, oxygen, and steroid
ICS-containing regimen, technique, action plan, and early follow-up
Recognize severity before silence
Assess respiratory rate, pulse, speech, accessory muscles, mental status, oxygen saturation, PEF or FEV1 when feasible, and response to initial therapy. A quiet chest, exhaustion, drowsiness, confusion, cyanosis, poor respiratory effort, or rising carbon dioxide indicates life-threatening airflow limitation and need for urgent escalation.
Treat airflow and inflammation
Give repeated inhaled rapid bronchodilator through an effective device, add ipratropium for severe attacks, provide controlled oxygen when hypoxemic, and give systemic corticosteroid promptly for moderate or severe exacerbation or incomplete response. GINA 2026 permits ICS-formoterol as an alternative reliever for selected mild acute presentations, subject to age, local protocol, and product context.
Give epinephrine first for anaphylaxis
When acute wheeze occurs with anaphylaxis features, give intramuscular epinephrine first and then bronchodilators and the broader anaphylaxis pathway. Inhaled albuterol does not treat hypotension, upper-airway edema, or mast-cell mediator release.
Prevent the next attack
Before discharge, confirm improvement and safe oxygenation, supply an ICS-containing regimen and adequate medicines, check technique, remove avoidable triggers, provide a written action plan, state maximum reliever use and emergency thresholds, and arrange early follow-up. Review every exacerbation as a preventable-system event.
Quick check
Module test
Check the connections.
Each attempt draws 10 questions from the complete 104 question bank.
Each attempt draws a fresh set and rearranges the answer choices.
References
Current clinical foundation.
Lecture material was synthesized with the following contemporary guidance. Verify local policy and current guidance before applying clinical information.