The GINA 2026 Guidelines introduce key updates in asthma management for both adult and pediatric patients, particularly around acute exacerbation care, wider use of anti-inflammatory reliever therapies, and strategies to minimize exposure to systemic corticosteroids.
These recommendations from the Global Initiative for Asthma (GINA) emphasize earlier, standardized, prevention-focused management of severe exacerbations, with direct implications for hospitals, emergency departments, and primary care.
Key Updates in Asthma Diagnosis and Treatment
New Exacerbation Algorithms for Adults and Children
GINA 2026 developed four new flowcharts for assessment, treatment, and follow-up of patients presenting with an asthma exacerbation/acute asthma, covering:
- Adults, adolescents, and children (6–11 years) presenting to primary care.
- Adults, adolescents, and children aged 6–11 years presenting to urgent care settings or emergency departments.
- Children aged 5 years and younger presenting to primary care.
- Children aged 5 years and younger presenting to urgent care settings or emergency departments.
These algorithms aim to standardize clinical decision-making and improve the early identification of severe or life-threatening cases.
Asthma Clinical Assessment According to GINA 2026 and Validated Pediatric Scales
Each flowchart provides criteria for mild, moderate, severe, and life-threatening presentations. Along with recommendations for initial treatment, subsequent management, and follow-up care.
For children and adolescents up to 17 years of age, there is a strong recommendation to use validated clinical scoring systems to assess severity, with examples provided for the Pediatric Respiratory Assessment Measure (PRAM).
Anaphylaxis and Asthma Management in GINA 2026
If the patient presents features of anaphylaxis in addition to asthma, each flowchart includes a recommendation to administer epinephrine (adrenaline) first, followed by bronchodilators. Epinephrine may be administered via intramuscular (IM) or intranasal routes; although the intranasal route not suitable for young children.
New Oxygen Saturation Targets in Asthma Patients According to GINA 2026
Oxygen saturation (SatO2) thresholds and targets have been lowered, and supplemental oxygen is not recommended unless oxygen saturation falls below 92%.
- If oxygen is administered, the upper target oxygen saturation limit for adults, adolescents, and children aged 6–11 years is 95%.
- In children aged 5 years and younger with acute wheezing or severe asthma exacerbations, the target oxygen saturation, when oxygen is administered, is ≥92%.
SABA Use in Asthma Exacerbations: Key Changes
Recommended doses of short-acting beta2-agonists (SABA) are more conservative due to increasing evidence of overtreatment during acute asthma exacerbations.
Overtreatment increases the risk of significant SABA-related toxicity, including lactic acidosis, which may cause compensatory hyperventilation. This can be misinterpreted as worsening asthma, potentially leading to additional SABA administration.
ICS-Formoterol: Anti-Inflammatory Reliever Therapy for Asthma
AIR Therapy with ICS-Formoterol from Early Asthma Stages
One of the changes in the GINA 2026 Guidelines is the expanded use of ICS-formoterol as an alternative to SABA in mild exacerbations and in anti-inflammatory reliever (AIR) strategies. Clinical evidence continues to demonstrate that ICS-formoterol-based regimens significantly reduce:
- Severe exacerbations
- Systemic corticosteroid use
- Emergency department visits
- Asthma-related hospitalizations
MART Therapy for Persistent Asthma
GINA continues to recommend Maintenance and Reliever Therapy (MART) as the preferred approach for many adult and adolescent patients due to its ability to simplify treatment and reduce inhaler use errors.
Proper Inhalation Technique with pMDI and Spacer in Acute Asthma
Each flowchart includes information on tidal breathing technique, as this is the most commonly used delivery method during acute asthma; however, the technique is often performed incorrectly.
Correct pMDI Administration During Acute Asthma
Salbutamol (albuterol) inhalers should be shaken immediately before each actuation to avoid inadvertent administration of ultra-high doses with a new inhaler (or lower doses if many doses have already been used). Any inhaler (pMDI – pressurized metered-dose inhaler) formulated as a suspension, including salbutamol and others, should be shaken immediately before each actuation.
New Biologic Therapies for Severe Asthma (eosinophilic and allergic)
New Biologics for Severe Eosinophilic Asthma
The guideline includes new biologic therapies:
- Depemokimab
- Omalizumab biosimilar (omalizumab-igec)
These therapies expand treatment options for patients with uncontrolled severe asthma and type 2 inflammatory phenotype
Reducing Oral Corticosteroid Use in Asthma Patients
GINA 2026 emphasizes optimization of oral corticosteroid (OCS) use to reduce both short- and long-term adverse effects. This includes optimizing inhaled therapy and using biologic therapy when indicated to prevent the need for OCS. It also recommends:
- Use non-pharmacological measures during respiratory infections
- Use appropriate OCS dose and duration when required
- Reserve OCS maintenance therapy as a last resort
- Monitor cumulative OCS exposure
Asthma Diagnosis in Adults, Adolescents, and Children Aged 6–11 Years
The diagnostic flowchart for asthma was simplified to improve clarity and usability.
Changes in Bronchodilator Response Criteria in Adults
- New data (large databases): In adults, some patients who were “positive” for bronchodilator response using the ERS/ATS 2005 criteria become “negative” when applying the 2022 criteria.
- ERS/ATS 2005 positive criterion: increase in FEV1 or FVC ≥12% and ≥200 mL from baseline.
- 2022 positive criterion: increase >10% of predicted value (in FEV1 or FVC).
- Clinical finding: patients who “convert to negative” under the 2022 criteria had a high respiratory disease burden.
- Clinical implication: relying solely on >10% of predicted may lead to underdiagnosis of asthma, particularly in young male patients.
Pediatric Asthma Treatment in Children Aged 6–11 Years According to GINA 2026
- AIR (Anti-inflammatory Reliever Therapy) with budesonide-formoterol (Steps 1–2, pediatrics): in the CARE study (children aged 5–15 years on SABA alone), low-dose “as-needed” budesonide-formoterol reduced the risk of moderate-to-severe exacerbations by almost 50% vs. SABA.
- Safety (growth): in the CARE study, no differences in growth velocity were observed with ICS-formoterol.
- Practicality: the ICS-formoterol formulation used in CARE was discontinued. GINA suggests an alternative.
- Evidence gap (6–11 years, Step 2): it is unclear whether “as-needed” ICS-formoterol is as effective as daily ICS plus as-needed SABA.
- MART (6–11 years): ICS-formoterol MART (Maintenance And Reliever Therapy) is an evidence-supported option for this age group in Steps 3–4.
- Transition between Steps 1–3 (6–11 years): the figure summarizes the best evidence by step but does not define how to escalate a single patient through Steps 1–2–3. GINA provides consensus-based suggestions grounded in Step 1 therapy.
- Treatment initiation (6–11 years): consensus recommendations on initial treatment step selection have been updated.
Asthma Treatment in Adults and Adolescents: GINA 2026 Updates
AIR with ICS-SABA in Step 1: Track 2 (Adults/Adolescents)
- AIR with ICS-SABA combination is introduced from Step 1.
- BATURA study: in poorly controlled asthma, as-needed ICS-SABA (either alone or as reliever in patients on daily ICS or LTRA) reduced the risk of severe exacerbations by almost half vs SABA alone.
Track 2: AIR with ICS-SABA Across All Steps
- AIR with ICS-SABA now appears across all steps in Track 2.
- In Steps 2–5, two inhalers are used → patient education is essential: distinguish controller vs reliever inhalers and provide inhaler technique training, especially when different devices are used.
AIR with ICS-Formoterol Remains Preferred: Track 1
- Track 1 with ICS-formoterol as an anti-inflammatory reliever remains the preferred approach (where available).
- Main reasons: it reduces severe exacerbations, systemic corticosteroid exposure, and urgent healthcare utilization compared with SABA-based regimens.
- Operational advantage: simpler regimen (one combination, one device, same dosing across Steps 1–4), with fewer technique errors and reduced selective non-adherence.
- Use only ICS–formoterol combinations (with formoterol as the LABA) for anti-inflammatory reliever therapy; do not use other ICS–LABA combinations for this purpose.
• AIR/MART dosing: simplified instructions (focused on the most commonly used ICS-formoterol formulations).
Safety Considerations for Reliever Inhaler Overuse
The concept of a “maximum dose” is replaced with guidance to advise patients to seek medical attention if they require more than a specified number of inhalations within 24 hours. A similar message is also added for SABA.
Step 5: Triple Therapy and LAMA in Uncontrolled Asthma
- Updated evidence supports the addition of LAMA (Long-acting muscarinic antagonists) in Step 5.
- An additional triple combination is included: ICS-LABA-LAMA (budesonide-formoterol-glycopyrronium) for uncontrolled asthma despite medium-dose ICS-LABA therapy.
- The reduction in severe exacerbations with triple therapy vs. ICS-LABA is smaller than that achieved with biologics. But it may be useful in patients who are not eligible for biologic therapy.
Importance of Pulmonary Function Testing in GINA 2026
The update further reinforces the importance of objective assessment of pulmonary function in the diagnosis and monitoring of asthma.
Spirometry in Asthma Diagnosis and Monitoring
Spirometry remains a fundamental tool for the diagnosis and monitoring of asthma. The guideline recommends using this test to:
- Confirm the diagnosis
- Assess bronchodilator response
- Monitor asthma control
- Guide therapeutic decisions
GINA strongly recommends performing spirometry in all patients (or peak expiratory flow [PEF] if spirometry is not available), except in preschool children or in life-threatening presentations. It also recommends repeating the test prior to hospital discharge.
The guideline further suggests reassessing the patient’s response after the initial bronchodilator administration and avoiding prescribing multiple SABA doses without reassessment. If there is no improvement in primary care (PC), immediate referral to a higher level of care is recommended.
Pulmonary Function Tests to Confirm Asthma in Adults and Children
This new guideline considers an acute asthma episode an opportunity to confirm the diagnosis of asthma. For this purpose, it recommends measuring pulmonary function before and after bronchodilator administration.
It also emphasizes documenting the asthma diagnosis and pulmonary function results in the patient’s medical record. In preschool children, it suggests documenting whether there was a clinical response to bronchodilator ± systemic corticosteroids. Recommendations regarding asthma diagnosis in preschool children were updated in GINA 2025.
Key Takeaways from the GINA 2026 Asthma Updates
GINA 2026 prioritizes an anti-inflammatory reliever-based approach for adults and adolescents, with Track 1 (ICS-formoterol/AIR and MART) as the preferred strategy to reduce severe exacerbations and systemic corticosteroid exposure. Track 2 incorporates ICS-SABA as AIR from Step 1 onward, emphasizing education on the use of two inhalers, safety limits related to excessive inhalations, and consideration of LAMA/triple therapy in Step 5 when asthma remains uncontrolled.
For healthcare professionals and institutions, these updates represent an opportunity to optimize clinical protocols and strengthen evidence-based respiratory care.
Pulmonary Function Testing Technologies Aligned with GINA 2026
The GINA 2026 recommendations reinforce the importance of respiratory function assessment for the diagnosis, monitoring, and follow-up of asthma. The SCHILLER-GANSHORN pulmonary solutions portfolio integrates advanced technologies for pulmonary function testing, powered by LFX software.
SpiroScout. Ultrasonic spirometer for performing this test, strongly recommended by GINA 2026.
tremoflo®: Airway oscillometry as a complementary test to spirometry.
PowerCube Diffusion+. Measurement of carbon monoxide diffusing capacity (DLCO).
PowerCube Body+: Body plethysmography system for advanced pulmonary function testing, available in XL versions and with wheelchair-access ramp options.
SCHILLER-GANSHORN’s pulmonary function testing solutions enable comprehensive respiratory assessment, supporting accurate diagnosis, patient monitoring, and evidence-based clinical decision-making. Spirometry, in particular, remains an essential tool for implementing the GINA 2026 recommendations for asthma care.
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Frequently Asked Questions About the GINA 2026 Asthma Guidelines
What are the most important updates in the GINA 2026 Asthma Guidelines?
GINA 2026 reinforces objective confirmation of asthma (preferably spirometry, or PEF where spirometry is unavailable). Continues to prioritize anti-inflammatory reliever–based management (Track 1 ICS–formoterol AIR/MART) to reduce severe exacerbations. It also clarifies escalation options for uncontrolled disease, including add-on LAMA/single-inhaler triple therapy in selected patients. And introduces/expands structured assessment and management pathways for acute exacerbations.
How does GINA 2026 recommend confirming an asthma diagnosis?
GINA 2026 recommends confirming asthma whenever possible by documenting variable expiratory airflow limitation. Spirometry performed before and after bronchodilator administration remains one of the preferred methods for establishing the diagnosis and reducing the risk of misdiagnosis.
Does GINA 2026 recommend spirometry for all asthma patients?
GINA 2026 strongly recommends spirometry (or PEF if unavailable) in the acute exacerbation setting for all patients except preschool children or life-threatening presentations. For diagnosis, spirometry with bronchodilator reversibility testing is the preferred method to document variable expiratory airflow limitation. For ongoing management, spirometry is primarily useful for identifying patients at increased risk of exacerbations rather than for routine treatment adjustment; symptoms and lung function are assessed separately.
What Pulmonary Function Tests Are Useful for Asthma Diagnosis and Monitoring?
ERS and GINA recommend spirometry (with bronchodilator reversibility) as the priority first-line test in adults and children ≥5 years with suspected asthma. FeNO is a recommended first-line complementary test (strong recommendation in children, conditional in adults ). PEF variability is recommended against as a primary test but may be used when spirometry is unavailable. Oscillometry is recommended for preschool children and non-collaborative patients. Body plethysmography (sGaw, RV/TLC) may complement diagnosis when preserved FEV1/FVC is present and diagnosis remains uncertain.