What deserves attention in the 2026 update?

The latest strategy is the GINA 2026 report, updated May 2026. Its acute-care pathways have been extensively revised. Oxygen is not routinely recommended when saturation is at least 92%; when needed in adults, adolescents and children aged 6–11 years, the target is 92–95%. Bronchodilator treatment should be reassessed rather than automatically repeated, with attention to beta-agonist toxicity. Anaphylaxis requires adrenaline first.

For adults and adolescents, ICS–formoterol remains the preferred reliever strategy. Track 2 now includes combined ICS–SABA at Step 1. New childhood AIR evidence and additional biologic options are also discussed. The report retains the adult bronchodilator-response criterion of an increase in FEV1 or FVC of at least 12% and 200 mL from baseline. Check the original age- and product-specific tables before prescribing; these are not interchangeable inhaler regimens.

The report’s acute-care boxes and medication tables should be used directly at the point of care. Earlier oxygen targets and older routine repeat-SABA instructions should not simply be carried forward into a 2026 protocol.

1. Start with a diagnosis you can explain

Ask what initially established the asthma label. Was there a compatible symptom history and documented variable airflow obstruction, or has the diagnosis simply followed the patient through years of repeat prescriptions? Record the evidence and the unresolved questions separately.

A useful history describes variability: episodes of wheeze, chest tightness, cough or breathlessness; night or early-morning symptoms; exercise, viral, seasonal or workplace associations; and periods of relative normality. Ask the patient to describe the sensation rather than accepting “wheeze” as a precise finding. A normal examination between episodes does not settle the question.

Make objective testing answer a specific question

Spirometry with bronchodilator testing is an appropriate starting point. Inspect test quality and the flow-volume loop as well as the numerical interpretation. If the first study is normal but suspicion remains, arrange reassessment during symptoms, a structured peak-flow record or specialist testing rather than treating a single negative result as definitive. Treatment already taken can make confirmation more difficult. The ERS adult diagnostic guideline discusses the role and limitations of these tests.

For the referral letter, include the actual pre- and post-bronchodilator values, dates, inhalers used and whether bronchodilators were withheld. “Spirometry normal” loses information that may change the interpretation. Do not withhold necessary treatment from a clinically unstable patient merely to obtain cleaner diagnostic measurements.

FeNO adds information; it does not replace the clinical assessment

In adults, FeNO above 50 ppb supports eosinophilic inflammation and a greater likelihood of corticosteroid responsiveness in the appropriate context. Values below 25 ppb make those features less likely; intermediate results need contextual interpretation. Neither a low value nor a high value is a stand-alone answer to “does this patient have asthma?” Atopy, allergen exposure, smoking and corticosteroid treatment can affect interpretation. See the ATS FeNO interpretation guideline.

Send the result with the clinical question: for example, “Persistent symptoms despite reported treatment use—please assess diagnosis, inflammatory phenotype and adherence.” A number without the treatment history is much less useful.

When the story does not fit

Consider upper-airway dysfunction, COPD, bronchiectasis, cardiac disease, deconditioning or another cause of cough and breathlessness. In South African practice, previous tuberculosis and possible active infection also belong in the history. Persistent focal findings, haemoptysis, systemic illness or an atypical radiograph warrant investigation rather than another empirical escalation of asthma therapy. The South African Thoracic Society position statement provides local clinical context; its 2021 publication date should be kept in mind when considering newer treatment evidence.

2. Structure the consultation around symptoms, attacks and treatment delivery

Use two separate opening questions: “How has your breathing affected your life recently?” and “What has happened when it has become bad?” They identify different problems. Someone may have few daily symptoms yet have needed emergency care twice; another may be persistently breathless for reasons that additional inhaled steroid will not resolve.

This is a suggested consultation workflow, not a validated scoring instrument. Its purpose is to make the next clinical decision explicit. “Poor control” is a description, not an explanation.

Before increasing treatment, check that the prescribed medicine is actually reaching the airways. A prescription history is not the same as use, and use is not the same as correct technique. Asking “How many doses did you miss last week?” often opens a more useful discussion than “Are you compliant?”

3. Prescribe a coherent anti-inflammatory treatment plan

Terminology: ICS = inhaled corticosteroid; SABA = short-acting beta-agonist; LABA = long-acting beta-agonist. Albuterol is the name used for salbutamol in the cited trials.

Relief of bronchoconstriction and prevention of future exacerbations should be considered together. In the Novel START trial, as-needed budesonide–formoterol prevented exacerbations more effectively than albuterol alone in adults with mild asthma. In SYGMA 2, as-needed budesonide–formoterol was noninferior to maintenance budesonide for severe exacerbations, although daily budesonide provided better symptom control. These findings help explain why infrequent symptoms do not justify relying only on bronchodilation.

AIR and MART are different instructions

AIR means an anti-inflammatory reliever. MART means maintenance-and-reliever therapy: scheduled treatment plus additional symptom-driven doses of the appropriate ICS–formoterol combination. A patient must know whether their prescription is reliever-only or includes regular maintenance. Avoid instructions such as “use as before” when changing between these approaches.

In the preferred adult/adolescent approach, lower-intensity treatment uses as-needed low-dose ICS–formoterol; patients needing more treatment use maintenance-and-reliever therapy, progressing from low to medium maintenance dosing according to assessment. Continuing difficulty requires review and specialist input rather than indefinite unsupervised escalation. The BTS/NICE/SIGN recommendations also support an AIR/MART approach for appropriate patients aged 12 years and over, while using their own diagnostic and treatment pathway.

When choosing the actual prescription

• Specify the medicine and device. Write the strength, scheduled doses if applicable, symptom-relief instruction and the personalised urgent-help threshold.
• Do not assume every combination inhaler is a reliever. Salmeterol- and vilanterol-containing maintenance combinations must not be used as rapid relievers. LABA monotherapy is not appropriate asthma treatment. Avoid combining separate LABA regimens without an explicit clinical rationale.
• Check metered versus delivered dose. Similar-looking numbers on devices do not prove equivalent dosing. Use the applicable product information and current treatment table.
• Check the local product. South African registration, approved ages, device availability and funding may differ from international trial settings.
• Remove contradictory instructions. Reconcile old repeats and explain which inhaler has been stopped, retained or repurposed.
• Plan supply. A patient using the same device for maintenance and relief needs enough medication to follow that prescription and a way to obtain the next inhaler before it runs out.

Have the patient explain the plan back in their own words: “What will you take on a good day? What will you take if symptoms start? When will you seek help?” This is a practical test of the prescription’s clarity.

Where ICS–SABA fits

The BATURA trial studied as-needed albuterol–budesonide in inadequately controlled mild asthma. Severe exacerbations occurred in 5.1% versus 9.1% with albuterol alone in the on-treatment analysis; almost all participants were adults. The MANDALA trial supports adding an anti-inflammatory component to rescue treatment in patients already receiving maintenance therapy for more substantial disease. These are specific regimens, not evidence that any ICS/LABA can be substituted for any other reliever.

When the preferred option is unavailable or unsuitable, choose a feasible ICS-containing alternative and make adherence and access part of the plan. Do not leave the patient with an unfillable prescription and no workable treatment.

Stepping down should be planned too

Once control is sustained, review whether treatment can be reduced safely. Choose a stable period, document the baseline, agree what deterioration would look like and arrange follow-up. Do not let a patient interpret feeling better as an instruction to abandon anti-inflammatory treatment. A history of serious attacks should weigh heavily in the decision.

4. Acute deterioration: recognise the limits of an elective referral

Assess speech, work of breathing, mental state, pulse, respiratory rate and oxygen saturation. Measure airflow when feasible without delaying treatment. Consider anaphylaxis and alternative acute diagnoses. Reassess the patient after intervention: a treatment chart with repeated doses is not a substitute for checking response.

The 2026 acute-care changes above are particularly relevant here. Use the current GINA report’s primary-care and emergency-care algorithms, alongside local emergency protocols, for severity-specific drug doses, monitoring and disposition. Worsening or inadequate improvement is a reason to escalate care, not simply continue the same treatment in the rooms.

The post-attack visit is a prevention visit

Arrange early reassessment after acute care. Reconstruct the sequence: first symptoms, medicines taken, response, delay in seeking help, access barriers and discharge instructions. Ask to see every inhaler. Check whether the patient understood the difference between a short course of oral steroid and continuing inhaled prevention.

Leave the patient with a written plan covering ordinary treatment, worsening symptoms, the relevant reliever instructions, urgent-help triggers and contact arrangements. Confirm that a follow-up appointment actually exists. A discharge letter recommending follow-up is not the same as a booked review.

Repeated steroid courses are a signal to rethink the pathway

Oral corticosteroids can be necessary for an exacerbation, but repeated bursts should not become a default maintenance strategy. A large population study by Waljee and colleagues associated short courses with increased rates of sepsis, venous thromboembolism and fracture. As observational evidence, it does not establish causality for every individual, but it reinforces the need to track exposure and use steroid-sparing prevention.

Keep a cumulative record rather than reviewing only the latest course. Include courses prescribed elsewhere, adverse effects, diabetes, bone health and any prolonged steroid use. Patients on long-term systemic steroids need supervised management; abrupt withdrawal can be unsafe.

5. When to refer to Dr Jason Edgar

Referral should answer a clinical question. It need not wait until every available inhaler has been tried. The following are practical referral prompts; urgency depends on the patient’s current condition and history.

Persistent uncontrolled disease is also a specialist referral point in the BTS/NICE/SIGN guideline authors’ summary. A routine referral threshold must never override a need for emergency assessment.

What specialist assessment may add

Dr Edgar’s practice offers full lung function testing with plethysmography and FeNO testing, alongside specialist respiratory assessment. These can help clarify the physiology and inflammatory context when clinically appropriate. Not every asthma referral requires every investigation; bronchoscopy and EBUS-TBNA are not routine asthma tests.

Where severe asthma is suspected, the assessment considers whether apparent treatment resistance reflects the disease itself, an incorrect diagnosis, delivery problems or associated conditions. Biologic selection is a specialist decision involving the clinical pattern, biomarkers, exacerbations and prior treatment. International evidence includes SWIFT-1 and SWIFT-2, in which twice-yearly depemokimab reduced exacerbation rates in severe eosinophilic asthma. This does not establish local availability, funding or suitability for a particular patient.

Send a referral that makes the first visit productive

• The diagnostic question and reason for referral, including urgency.
• Symptom pattern, functional impact, smoking/vaping and exposure history.
• Actual spirometry reports and loops, previous best lung function, peak-flow records and relevant imaging.
• FeNO and blood results where available, with dates and treatment at the time.
• Every inhaler’s name, strength, device and instructions; treatment trials and documented technique review.
• Steroid courses, emergency visits, admissions and any ICU/ventilation history.
• Relevant associated conditions, medication reactions and patient priorities.
• The current action plan and what primary care will continue to manage while the patient waits.

Do not delay a necessary referral while collecting a perfect set of tests. State what is unavailable. Referrals can be made by phone or email using the contact details below.

6. Applying the approach: three common consultations

The following are fictional teaching examples, not patient testimonials or individual prescriptions.

7. Children, pregnancy and other situations needing a separate plan

Do not scale an adult inhaler prescription down informally for a child. Device suitability, approved ages, dose limits and the evidence at each treatment step differ. GINA 2026 discusses new paediatric anti-inflammatory-reliever evidence, but an adult pathway is not a substitute for its age-specific guidance. Refer to an appropriate paediatric service when indicated.

Pregnancy, substantial cardiopulmonary comorbidity and prolonged systemic steroid exposure also require individualised planning. If the patient’s concern is medication safety, address it directly and arrange a coordinated review rather than allowing unplanned treatment discontinuation. For adolescent referrals, confirm the practice’s age arrangements with reception.

Source documents and further reading

The links throughout this article lead to the original guidance and studies. Start with the official GINA 2026 Strategy Report and 2026 Summary Guide for complete age-specific algorithms and medication instructions. Supporting sources are explicitly dated; older research is cited for the evidence it provides, not presented as a new 2026 recommendation.

Prepared 13 September 2026. This article supports professional judgement and does not replace a full guideline, local emergency protocol or medicine’s prescribing information. Recommendations, product availability and funding can change. GINA retains rights to its own publications; no GINA figures, tables or logos are reproduced here, and no endorsement is implied.