At SCHILLER, we understand that your time is valuable and that keeping up with clinical guidelines can be a challenging task. That’s why we’ve prepared this summary of the most important updates in the 2025 edition of the GINA (Global Strategy for Asthma Management and Prevention) Strategy Report—so you can quickly identify the new recommendations and, most importantly, what is no longer advised in asthma management.
Our commitment is to support you in your daily work by providing access to up-to-date, practical information for your clinical practice. We invite you to read and share this summary with your team and colleagues.
By América Torres
Interpretation of type 2 inflammation biomarkers
In the 2025 edition of the GINA Guidelines1, Type 2 inflammation biomarkers take on greater importance and are referenced throughout the document. In fact, they are specifically addressed in Appendix A.
This appendix states that Type 2 inflammation biomarkers in patients with asthma (measured in blood, urine, induced sputum, exhaled air, and bronchoalveolar lavage) should always be interpreted within an appropriate clinical context. For asthma management, the most useful biomarkers are those indicating Type 2 airway inflammation and allergy, such as:
- Blood eosinophil count
- Fractional exhaled nitric oxide (FeNO)
- Total serum immunoglobulin E (IgE)
- Allergen-specific IgE
According to the document, these biomarkers are helpful for diagnosis, phenotype identification, monitoring, prognosis, and predicting patient response to asthma treatment. It also notes that sputum eosinophil count can guide corticosteroid therapy in patients with moderate to severe asthma, although this test is not commonly available in clinical practice.
Risk factors for severe exacerbations in adolescent and adult patients
The ORACLE22 study supports GINA’s recommendation to assess multiple factors—including type 2 biomarkers—to estimate the risk of exacerbations. The analysis was based on data from patients in the placebo groups of clinical trials, although it was unable to assess SABA (short-acting beta2-agonist) overuse due to lack of data. Similar studies are needed in real-world populations, along with risk-reduction strategies based on the identified factors. The study also highlights the important role of environmental factors, such as air quality, in reducing exacerbations.
GINA 2025 addresses the impact of climate change on asthma
The GINA 2025 Report addresses the impact that climate change and extreme weather events (such as heatwaves, cold spells, heavy rainfall, and droughts) have on people with asthma. It groups the negative effects of climate into two main categories:
- Infrastructure. Climate-related disasters can damage healthcare infrastructure, potentially disrupting access to medical care.
- Air pollution. The presence of air pollutants, the survival of respiratory viruses, and the increased concentration of allergens in the air can worsen asthma. The document also notes that thunderstorms may trigger asthma exacerbations and even epidemic outbreaks.3
Diagnostic criteria in children aged 5 years and younger
The 2025 edition of the GINA Report confirms that it is possible to diagnose asthma in this age group and clearly outlines the three criteria that must be met:
- Recurrent acute episodes of wheezing, or at least one acute episode of wheezing accompanied by asthma-like symptoms between episodes.
- No other likely alternative cause for the respiratory symptoms.
- Timely clinical response of respiratory signs or symptoms to asthma treatment. Any of the following options:
- Rapid response to SABA (short-acting beta2-agonist) during acute wheezing episodes in a healthcare setting (within minutes), or, in more severe cases, within 3–4 hours after starting treatment with SABA and oral corticosteroids (OCS).
- Rapid response to SABA at home, with symptom improvement within minutes.
- Decrease in the frequency or severity of acute wheezing episodes and/or symptoms between episodes during a 2–3 month diagnostic trial with daily inhaled corticosteroids (ICS).
To establish a diagnosis of asthma in this age group, all three criteria above must be met. If only one or two are met, it should be recorded as suspected asthma.
Treatment of asthma in children aged 5 years and younger
The GINA Strategy Report 2025 updates the therapeutic approach to asthma in children under 5 years of age (see treatment figure below) with a confirmed diagnosis, highlighting the limited availability of options for children who present asthma symptoms on ≤2 days per week and have no history of severe episodes. New alternatives are currently being investigated, such as low-dose ICS-formoterol as an anti-inflammatory reliever therapy in this age group.
Exacerbations in children aged 5 years or younger: new saturation threshold, nebulized magnesium
- The recommendation to use intravenous magnesium sulfate in moderate or severe exacerbations is reinforced.
- The use of nebulized magnesium sulfate is discouraged.
- Changes to the dosing of inhaled medications during intensive care have been included.
- The target oxygen saturation has changed from 94–98% to ≥94%, with a reminder to consider skin color and to make altitude adjustments if relevant (for this and all age groups).
Biomarkers for the diagnosis of asthma in adults and adolescents
- The diagnostic algorithm for asthma in adults and adolescents has been revised to make it clearer. The limited role of biomarkers was added (see Appendix A).
- Lung function assessment remains the first choice to confirm the diagnosis.
New definition of asthma
The term “variable expiratory flow limitation” caused confusion and has been replaced with “variable expiratory flow.” GINA indicates that in untreated asthma patients, lung function varies, so airflow limitation may be present at times and absent at others. The document clarifies that GINA has never intended to imply that airflow limitation must be present during diagnostic evaluation.
Relevance of elevated FeNO
In the “Review” section of the asthma management cycle chart, the indication to “Consider biomarkers” was added. GINA notes that FeNO suppression studies have shown that, in many patients, elevated FeNO levels are due to poor adherence to inhaled corticosteroid (ICS) treatment. Therefore, it is better to consider biomarkers after starting such treatment to assess adherence and inhalation technique.
Population-based and personalized treatment decisions
Population-based decisions are grounded in reliable group evidence and have been part of the GINA recommendations since 2014. For individual decisions, physicians are advised to consider phenotypic characteristics (including biomarkers), comorbidities, patient perspectives, and practical aspects.
Fenoterol is no longer recommended. New dosage for fluticasone furoate and for ICS-LABA combinations
- Fenoterol has been added to the list of bronchodilators not recommended due to its high risk of causing adverse cardiovascular effects and asthma-related mortality.
- GINA 2025 maintains the two-track treatment strategy for adolescents and adults, prioritizing Track 1 with ICS-formoterol as the anti-inflammatory reliever medication (when available), since it reduces the risk of severe exacerbations, corticosteroid exposure, and urgent care needs compared to SABA (Short-Acting Beta 2-Agonist)-based regimens.
- In Track 2, Step 4 has changed from medium-to-high dose ICS-LABA to medium dose ICS-LABA (Inhaled corticosteroid Long-acting beta 2-agonist) to minimize adverse effects associated with high doses of ICS. If high-dose ICS-LABA is needed, its use should be limited to 3–6 months whenever possible.
- The daily doses of fluticasone furoate have been reclassified: 100 mcg as low-medium and 200 mcg as medium-high.
- In the GINA 2025 edition, the “other controller options” that previously appeared in gray boxes under each step (p. 77) were removed. These options, which had lower evidence of efficacy and/or safety, were replaced by explanatory text. The goal is to prevent delays in referring patients with difficult-to-control asthma to a specialist by avoiding trials of multiple additional treatments without proven effectiveness.
Shared decision-making for inhaler choice
The GINA Strategy Report 2025 updates its approach to inhaler selection by emphasizing that the priority is to choose the most appropriate medication for the patient. Only if the medication is available in multiple devices that the patient can use correctly should the environmental impact be considered as an additional factor in the shared decision-making process.
Changes in asthma treatment action plans
- For patients using conventional treatment based on SABA (Track 2), the use of SABA to relieve symptoms is increased.
- There is only limited evidence that doubling or quadrupling the maintenance dose of inhaled corticosteroids (ICS) reduces progression to a severe exacerbation defined as the need for oral corticosteroids (OCS).
- In contrast, for patients using ICS-formoterol as anti-inflammatory rescue medication (Track 1), the usual maintenance dose is continued, but rescue doses are increased as needed to control the increase in inflammation and bronchoconstriction. In this case, there is strong evidence of a significant reduction in the risk of severe exacerbations requiring OCS or urgent medical care.
Treatment of severe exacerbations in adults, adolescents, and children aged 6 to 11 years
- The doses of SABA for initial treatment in primary care and emergency services were specified to avoid excessive use.
- The use of nebulized magnesium is no longer recommended.
Spirometry is a reliable test for diagnosing asthma
The Global Strategy for Asthma Management and Prevention (GINA) states that spirometry is a reliable tool to assess lung function. This test measures key parameters such as forced expiratory volume in the first second (FEV1) and the FEV1/FVC ratio (forced vital capacity). Additionally, GINA emphasizes that spirometry should be performed by trained personnel, using well-maintained and properly calibrated equipment, and employing filters to prevent infection transmission. This is where SpiroScout makes the difference.
This state-of-the-art spirometer not only meets GINA requirements—it exceeds them. Thanks to its SharpFlow ultrasonic technology, SpiroScout requires no calibration, ensuring precise and reliable measurements. Its intuitive design makes it easy to use, allowing staff to operate the device with a minimal learning curve.
Regarding biosafety, SpiroScout offers a double layer of protection:
- The ScoutTube mouthpieces, which feature a protective membrane to prevent cross-contamination.
- And for maximum safety, the system includes the SpiroDef, a filter that effectively eliminates aerosols, bacteria, and viruses, ensuring total hygiene.
Additionally, the LFX software that accompanies SpiroScout (and all our pulmonary function tests) provides valuable clinical features:
- Automatically verifies if the test meets the quality criteria established by ATS/ERS.
- Includes visual graphics (candles, fish, and clouds) to make the test more friendly for children and guide them to perform the maneuver correctly.
- LFX also enables the comparison of multiple tests to objectively evaluate the patient’s response to treatment.
We invite you to watch this short video that explains the differences between oscillometry and spirometry, and the advantages of each test.
Asthma diagnosis from age 4 onwards
According to GINA, in children, spirometry cannot be reliably obtained until the age of 5 years or older. That is why at SCHILLER-GANSHORN we developed the tremoflo®, our airway oscillometer that allows pulmonary function assessment in very young children: from 4 years of age onward.
See the advantages of oscillometry for performing reliable tests in small patients as well as in those with neurological problems or who have difficulty performing the spirometry maneuver.
At SCHILLER-GANSHORN, we offer a complete line of pulmonary function tests for diagnosing and monitoring patients with asthma, COPD, and other respiratory diseases. As the first manufacturer to implement ultrasound technology across our entire PFT line, we continue to lead through innovation, delivering precise, user-friendly solutions that elevate clinical care.
Working with innovators means staying ahead. By partnering with SCHILLER-GANSHORN, you gain access to cutting-edge technology backed by decades of expertise in respiratory diagnostics. We invite you to schedule a personalized consultation with one of our specialists. During this session, you’ll explore the SpiroScout spirometer and the tremoflo® oscillometer, share your practice’s needs, and receive expert guidance to help you choose the best-fit equipment. The consultation is completely free and without obligation. Book a one-on-one session today!
REFERENCES
[1] Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025. Updated May 2025. Available from: www.ginasthma.org
[2] Meulmeester FL, et al. Inflammatory and clinical risk factors for asthma attacks (ORACLE2): a patient-level meta-analysis of control groups of 22 randomised trials. Lancet Respir Med. 2025 Jun;13(6):505-516. DOI: 10.1016/S2213-2600(25)00037-2 Epub 2025 Apr 8. PMID: 40215991; PMCID: PMC12117016.
[3] Dwan Price PhD et al. Epidemic Thunderstorm Asthma: Lessons Learned from the Storm Down-Under. The Journal of Allergy and Clinical Immunology: In Practice Volume 9, Issue 4, April 2021, Pages 1510-1515. DOI: https://doi.org/10.1016/j.jaip.2020.10.022
