Asthma

GINA 2025: chronic airway inflammation with variable, reversible obstruction

Respiratory

Recognize

Wheeze, cough (often at night or early morning), chest tightness, dyspnea.
Triggers: allergens, smoke, cold air, exercise, viral infections, aspirin/NSAIDs in some, beta blockers, stress.

Danger signs of a severe attack

Can't speak in full sentences; accessory muscle use; SpO₂ <90%.
"Silent chest": little air movement, so wheezing disappears.
Drowsy or confused; normal or rising PaCO₂ = tiring out.

Peak flow zones

Green ≥80%	of personal best: continue usual plan
Yellow 50–79%	use reliever; follow action plan; contact provider
Red <50%	use reliever now; seek emergency care

Measure: stand, full breath, seal lips, blow hard and fast; best of 3.

Long-term treatment (adults and adolescents ≥12) Updated

Preferred (GINA Track 1): the reliever is low-dose ICS-formoterol (budesonide-formoterol) taken as needed.

Mild asthma: as-needed ICS-formoterol only.
Moderate to severe: maintenance-and-reliever therapy (MART): the same ICS-formoterol inhaler every day and as needed.

SABA alone (albuterol only) is no longer recommended: it treats symptoms but not inflammation and increases the risk of severe attacks and death.

If albuterol is the reliever (Track 2), take an inhaled corticosteroid too, every time or daily.

Add-ons: LAMA, montelukast (boxed warning: mood and behavior changes), biologics (omalizumab, mepolizumab, benralizumab, dupilumab, tezepelumab).

Acute exacerbation

SABA (albuterol) repeated, e.g., every 20 min in the first hour; add ipratropium if severe.
Systemic corticosteroid early (oral prednisone or IV).
Oxygen to SpO₂ 93–95% adults (94–98% children).
IV magnesium sulfate for severe attacks not responding.
No sedatives. Prepare for intubation if tiring.

Inhaler technique

MDI: shake; breathe out; seal lips (spacer preferred); press once and breathe in slowly over 3–5 s; hold ~10 s; wait 30–60 s between puffs.
Dry powder inhaler: don't shake; don't breathe into it; breathe in fast and deep.
Rinse mouth and spit after a steroid inhaler (prevents thrush).
Two inhalers: bronchodilator first, then the steroid.

Priority LABA (salmeterol, formoterol) is never used alone in asthma: always combined with an inhaled corticosteroid. A patient whose wheezing "stops" while still struggling to breathe is getting worse, not better.