Managing Acute Asthma in 2026: A Practical Guide to the GINA Recommendations

From initial severity assessment to bronchodilator treatment, escalation, discharge and prevention of recurrent exacerbations

The 2026 Global Initiative for Asthma (GINA) Strategy Report introduces a more structured approach to acute asthma, including new flowcharts for patients presenting in primary care and acute-care settings. For adults and adolescents, the key principles are rapid recognition of severity, prompt bronchodilator and anti-inflammatory treatment, objective reassessment and early escalation when response is inadequate.

The update also changes several practical elements of acute care, including oxygen thresholds, SABA dosing and the role of ICS–formoterol. The emphasis is less on automatically adding more treatment and more on giving appropriate initial therapy, measuring the response and recognising failure early.

What has changed in GINA 2026?

GINA identifies acute asthma management as a major focus of the 2026 update. Four new flowcharts cover presentation, treatment and follow-up across primary and acute care.

GINA also now explicitly states that when a patient presents with both anaphylaxis and asthma, epinephrine should be given first, followed by bronchodilator therapy.

How should the initial assessment be approached?

Assessment and treatment should occur at the same time. A focused history and examination should not delay bronchodilator therapy, oxygen when indicated or urgent escalation.

The immediate clinical question is not simply, “Is this mild, moderate or severe?” The more useful sequence is:

ACUTE ASTHMA PRESENTATION
          │
          ▼
ASSESS WHILE STARTING TREATMENT
          │
          ▼
Any immediately life-threatening features?
          │
     ┌────┴────┐
     │         │
    YES        NO
     │         │
     ▼         ▼
URGENT ICU   Assess overall severity
ESCALATION   + objective airflow limitation
     │         │
     └────┬────┘
          ▼
START / ADJUST TREATMENT
          │
          ▼
REASSESS RESPONSE

A focused assessment should include:

• degree of dyspnoea;
• respiratory rate;
• ability to speak;
• accessory muscle use;
• pulse and blood pressure;
• level of consciousness;
• oxygen saturation; and
• lung function with PEF or FEV₁, where feasible.

Objective measurements matter because physical examination alone can underestimate the severity of airflow obstruction. GINA strongly recommends lung-function measurement where possible, provided it does not delay urgent treatment. PEF or FEV₁ should then be followed during treatment, including at around one hour and until a clear response or plateau has been reached.

The assessment should also consider an alternative or additional diagnosis, particularly pneumothorax, pneumonia, pulmonary embolism, cardiac failure, inducible laryngeal obstruction or diabetic ketoacidosis.

Which findings should trigger immediate ICU escalation?

Certain findings should override routine severity categorisation.

Drowsiness, confusion or a silent chest should prompt immediate transfer to intensive care. Treatment should continue while transfer is being arranged, including inhaled SABA, ipratropium, controlled oxygen and systemic corticosteroids.

This is clinically important because apparently reduced respiratory effort is not always reassuring. A quieter patient with diminishing air entry, exhaustion or altered consciousness may be deteriorating.

DROWSY / CONFUSED / SILENT CHEST
               │
               ▼
      LIFE-THREATENING ASTHMA
               │
               ▼
      IMMEDIATE ICU TRANSFER
               │
               ▼
Continue acute treatment during transfer

How should oxygen be used in 2026?

The oxygen recommendation is one of the clearest changes.

GINA suggests supplemental oxygen when SpO₂ is <92%. When oxygen is required, it should be titrated to a target saturation of 92–95%.

               SpO₂
                 │
          Is SpO₂ <92%?
           /           \
         NO             YES
         │               │
         ▼               ▼
No routine oxygen   Give controlled O₂
                         │
                         ▼
                  Target 92–95%
                         │
                         ▼
                 Reassess frequently

In adults with severe exacerbations, controlled low-flow oxygen targeting approximately 93–95% has produced better physiological outcomes than high-concentration oxygen. Oxygen should not, however, be withheld from a hypoxaemic patient solely because pulse oximetry is unavailable.

GINA also cautions that pulse oximetry can overestimate oxygen saturation in people with darker skin colour, and targets may need adjustment at altitude.

What is the preferred bronchodilator approach?

Inhaled salbutamol (albuterol) remains the usual bronchodilator in acute asthma.

Delivery by pMDI with spacer produces a similar improvement in lung function to nebulised treatment in the populations studied, with lower cost; however, patients with life-threatening asthma were generally excluded from these comparisons.

GINA 2026 recommends more conservative SABA dosing than in the past, reflecting concern about overtreatment and toxicity.

High SABA exposure may cause:

• tachycardia and palpitations;
• anxiety and tremor;
• hypokalaemia;
• arrhythmias;
• lactic acidosis; and
• compensatory hyperventilation.

The last point is particularly important. Hyperventilation caused by SABA-associated lactic acidosis can be mistaken for worsening asthma, potentially leading to further unnecessary bronchodilator administration.

For milder presentations, GINA therefore emphasises reviewing the patient's response after the initial bronchodilator, rather than automatically administering multiple further doses.

Any suspension pMDI, including salbutamol, should be shaken immediately before each actuation.

When should ipratropium be added?

For adults with moderate-to-severe exacerbations, adding inhaled ipratropium to SABA in the emergency department is associated with fewer hospitalisations and greater improvement in PEF and FEV₁ than SABA alone. The evidence for reduced hospitalisation in adults is graded Evidence A.

This makes ipratropium an important part of early treatment in more severe acute presentations, rather than a routine long-term reliever.

GINA also states that there is no benefit from continuing ipratropium beyond the first 1–2 hours of treatment.

Where does ICS–formoterol fit?

GINA 2026 adds ICS–formoterol as an option for mild exacerbations presenting to primary care or the emergency department, as an alternative to inhaled SABA.

This is clinically relevant because it allows the patient to continue or establish an anti-inflammatory reliever strategy during the acute episode rather than relying exclusively on SABA.

The direct ED evidence remains relatively limited. GINA cites a randomised trial in adults and adolescents with mean baseline FEV₁ around 42–45% predicted. Budesonide–formoterol and salbutamol produced similar lung-function trajectories over three hours, although pulse rate was higher with SABA; all patients also received oral corticosteroids. GINA notes that further studies are required.

This should therefore be interpreted as a new treatment option for selected mild exacerbations, not evidence that ICS–formoterol has replaced standard acute bronchodilator management across all severity levels.

When should systemic corticosteroids be started?

Systemic corticosteroids speed resolution and reduce relapse and should be used in all but the mildest exacerbations in acute-care settings. GINA grades this Evidence A and recommends administration within 1 hour of presentation where possible.

They are especially important when:

• initial SABA does not produce lasting improvement;
• the exacerbation developed while the patient was already taking OCS; or
• there is a previous history of exacerbations requiring OCS.

For adults, GINA gives a recommended acute dose of prednisone/prednisolone 1 mg/kg/day up to a maximum of 50 mg/day, usually for 5–7 days.

Oral treatment is as effective as intravenous corticosteroid therapy and is preferred because it is faster to administer, less invasive and less expensive. IV treatment is appropriate when the patient cannot swallow, is vomiting or requires ventilatory support.

Repeated OCS exposure is clinically important. GINA highlights both short-term adverse effects and cumulative long-term risk, strengthening the case for optimising asthma treatment after every severe exacerbation.

Why is reassessment so important?

GINA 2026 places strong emphasis on response to treatment, not just initial severity.

Symptoms, oxygen saturation and lung function should be reassessed after initial bronchodilator therapy and again at approximately 1 hour or earlier, with treatment adjusted to the patient's response.

INITIAL TREATMENT
      │
      ▼
REASSESS
Symptoms • SpO₂ • PEF/FEV₁
      │
 ┌────┼───────────┐
 │    │           │
 ▼    ▼           ▼
Better Persistent Deteriorating
 │    │           │
 ▼    ▼           ▼
Reduce/ Continue   Escalate
stop    treatment  urgently
repeated + reassess
dosing

Clinical status and lung function at one hour are more reliable predictors of the need for hospitalisation than the patient's condition at presentation.

Admission decisions should also take account of previous severe exacerbations, previous intubation or admission, response to initial bronchodilator therapy, final lung function and the patient's social circumstances and ability to manage safely at home.

When should arterial blood gases be obtained?

Arterial blood gases are not routinely required.

GINA advises considering blood gases when PEF or FEV₁ is <50% predicted, when the patient is not responding adequately to initial treatment or when there is clinical deterioration.

During an asthma exacerbation, PaCO₂ is usually low because of hyperventilation. Fatigue, somnolence and a normalising or rising PaCO₂ should therefore raise concern for ventilatory failure.

GINA states that PaO₂ <60 mmHg (8 kPa) with normal or increased PaCO₂, particularly >45 mmHg (6 kPa), indicates respiratory failure.

POOR RESPONSE / DETERIORATION
             │
             ▼
Consider ABG
             │
             ▼
Normal or rising PaCO₂?
             │
            YES
             │
             ▼
   CONCERN FOR RESPIRATORY FAILURE
             │
             ▼
       ICU / AIRWAY REVIEW

What if severe asthma persists despite initial therapy?

Persistent severe asthma should trigger structured escalation, not simply repeated bronchodilator doses without review.

Core treatment should be continued and optimised while the patient is reassessed.

PERSISTENT SEVERE ASTHMA
          │
          ▼
Continue core treatment
SABA + ipratropium
systemic corticosteroid
oxygen if hypoxaemic
          │
          ▼
Objective reassessment
          │
    ┌─────┴──────┐
    │            │
Selected severe  Deteriorating /
poor response    respiratory failure
    │            │
    ▼            ▼
Consider IV      ICU / expert
magnesium        airway management

When should IV magnesium sulphate be considered?

IV magnesium sulphate is not recommended routinely.

GINA reports that a single 2 g IV infusion over 20 minutes reduces hospital admission in selected patients who fail to respond to initial treatment and have persistent hypoxaemia, including adults presenting with FEV₁ <25–30% predicted. This is supported by Evidence A.

Nebulised magnesium has not shown significant benefit in adults and adolescents and is not recommended for routine use.

Should aminophylline or theophylline be added?

No.

GINA states that intravenous aminophylline and theophylline should not be used in acute asthma exacerbations because of poor efficacy, an unfavourable safety profile and the greater effectiveness and relative safety of SABA.

In adults with severe exacerbations, adding aminophylline to SABA does not improve outcomes. Toxicity may include nausea, vomiting and potentially serious or fatal adverse effects, particularly in patients already receiving sustained-release theophylline.

What treatments should not be used routinely?

Routine antibiotics are not supported unless there is convincing evidence of bacterial lung infection, such as fever, purulent sputum or radiographic pneumonia.

Sedation deserves particular emphasis. GINA states that it should be strictly avoided because respiratory depression may contribute to avoidable asthma deaths.

What is the role of non-invasive ventilation?

Evidence for non-invasive ventilation (NIV) in acute asthma remains weak.

GINA does not make a recommendation for routine NIV because the available studies are small and the evidence quality is low. If NIV is attempted, the patient should be monitored closely with the ability to escalate rapidly.

NIV should not be attempted in an agitated patient, and the patient should not be sedated simply to facilitate NIV.

Importantly, NIV should not delay ICU transfer or definitive airway management when respiratory failure is developing.

When should ICU transfer be considered?

GINA advises re-evaluating patients for intensive care when they deteriorate despite intensive bronchodilator and corticosteroid treatment.

Immediate ICU transfer is required for drowsiness, confusion or a silent chest. Progressive exhaustion, worsening hypoxaemia, rising PaCO₂ and failure to respond to treatment should also prompt urgent critical-care involvement.

GINA explicitly states that management of asthma in the ICU is beyond the scope of the strategy report. Detailed invasive ventilation settings should therefore follow critical-care expertise and local protocols rather than being inferred from the GINA acute-care pathway.

What should happen before discharge?

Discharge planning is part of acute asthma management rather than an administrative afterthought.

Before leaving the ED or hospital, patients should have their long-term asthma treatment reviewed and should be prescribed ongoing ICS-containing therapy. SABA-only treatment is not recommended.

For adults and adolescents, GINA identifies ICS–formoterol maintenance-and-reliever therapy (MART) as the preferred ongoing regimen after ED presentation or hospitalisation, where appropriate.

For adults, prednisone/prednisolone is typically prescribed at 40–50 mg/day for 5–7 days at discharge.

Patients should use their reliever as needed rather than routinely, and inhaler technique and adherence should be reviewed before discharge. Follow-up should generally occur within 2–7 days.

Patients should be referred for expert advice if they have had one or more exacerbations requiring OCS or urgent healthcare in the previous 12 months, or if ICU care was required.

Why does the post-exacerbation review matter?

A severe exacerbation predicts future risk.

GINA therefore treats the episode as a warning that long-term asthma management requires review. The aim is to reduce recurrent exacerbations and future exposure to systemic corticosteroids.

After an ED presentation or hospitalisation, GINA states that MART with ICS–formoterol reduces the risk of another severe exacerbation over the following year by 32% compared with the same dose of ICS or ICS–LABA plus as-needed SABA, and by 23% compared with higher-dose ICS–LABA plus as-needed SABA in patients with a history of at least one severe exacerbation.

The review should address treatment adherence, inhaler technique, the reason for the exacerbation, modifiable risk factors and the patient's written action plan.

The acute asthma pathway at a glance

              ACUTE ASTHMA
                    │
                    ▼
        ASSESS WHILE TREATING
 Symptoms • RR • speech • SpO₂ • PEF/FEV₁
                    │
                    ▼
       LIFE-THREATENING FEATURES?
     Drowsy • confused • silent chest
             /                \
           YES                 NO
            │                   │
            ▼                   ▼
       IMMEDIATE ICU        START TREATMENT
          TRANSFER              │
                                ▼
                 ┌──────────────┼──────────────┐
                 │              │              │
                 ▼              ▼              ▼
              SABA        Ipratropium      OCS early
                           if moderate/
                              severe
                 │
                 ▼
          O₂ IF SpO₂ <92%
          target 92–95%
                 │
                 ▼
             REASSESS
     symptoms • SpO₂ • PEF/FEV₁
                 │
        ┌────────┼───────────┐
        │        │           │
        ▼        ▼           ▼
    Improved  Persistent   Deteriorating
                severe
        │        │           │
        ▼        ▼           ▼
  Prepare for Consider      ICU /
   discharge  IV MgSO₄      airway
             selectively    management
        │
        ▼
OPTIMISE ICS-CONTAINING THERAPY
ACTION PLAN + EARLY FOLLOW-UP

Clinical takeaway

GINA 2026 places greater emphasis on assessment and treatment occurring together, objective reassessment and early recognition of treatment failure.

For adults with acute asthma, oxygen is suggested when SpO₂ <92%, with a target of 92–95% when required. SABA remains central, but excessive repeated dosing should be avoided; ipratropium should be added in moderate-to-severe exacerbations, and systemic corticosteroids should be started promptly in all but the mildest acute-care presentations.

If severe asthma persists, the next step is not simply more bronchodilator. Selected patients may benefit from IV magnesium sulphate, while aminophylline/theophylline should not be used. Deterioration, altered consciousness, a silent chest or evolving respiratory failure should prompt urgent ICU involvement. Finally, every significant exacerbation should trigger optimisation of ICS-containing therapy and early follow-up to reduce the risk of recurrence.

Full reference

Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2026 update. Updated May 2026. Global Initiative for Asthma; 2026. Available from: www.ginasthma.org ↗. No DOI assigned.