What are asthma guidelines and why are they important?

The 2020 Focused Updates to the Asthma Management Guidelines are designed to improve the care of people living with asthma and also help primary care providers and specialists make informed decisions about asthma management.

These guidelines are based on the best available scientific evidence in selected topics and can be used by health care providers to develop appropriate treatment plans with their patients. Health care providers nationwide can use the information to deliver the best possible care to everyone living with asthma.

People with asthma can work with their health care providers to develop a comprehensive prevention and treatment plan based on these guidelines that includes:

  • Taking prescribed medications
  • Addressing environmental factors that may worsen symptoms
  • Learning how to better manage their asthma
  • Monitoring and adjusting care as needed

Why is it necessary to update the asthma guidelines?

NHLBI's first set of asthma guidelines, published in 1991, was last updated in 2007. Since then, researchers have made much progress in understanding the origins of asthma and how the disease evolves over time. In addition, the Food and Drug Administration (FDA) has approved several new asthma treatments.

The new guidelines help health care providers and people with asthma work together to develop a comprehensive management plan based on the most promising, evidence-based treatment options available.

Does the latest update represent a complete revision of the existing asthma treatment guidelines?

No. The 2020 Focused Updates to the Asthma Management Guidelines addresses health questions in six important areas. Other important aspects of care—such as asthma education and tools to assess asthma control and patient compliance—are not covered. These guidelines are meant to assist, not replace, the clinical decision-making required to meet individual patient needs.

What are the key points of the recommendations?

The 2020 Focused Updates to the Asthma Management Guidelines cover six priority topics in asthma care:

Intermittent Inhaled Corticosteroids

  • In children ages 0-4 years with recurrent wheezing, a short (7-10 day) course of daily inhaled corticosteroids along with an as-needed short-acting bronchodilator (e.g., albuterol sulfate) is recommended at the start of a respiratory tract infection.
  • In people ages 4 years and older with mild to moderate persistent asthma who use inhaled corticosteroids daily, increasing the regular inhaled corticosteroid dose for short periods is not recommended when symptoms increase or peak flow decreases.  
  • For people ages 4 and older with moderate to severe persistent asthma, the preferred treatment is a single inhaler that contains an inhaled corticosteroid and the bronchodilator formoterol. This should be used as both a daily asthma controller and quick-relief therapy.
  • People ages 12 and older with mild asthma may benefit from inhaled corticosteroids with a short-acting bronchodilator for quick relief. Treatment may include inhaled corticosteroids daily or as needed when asthma gets worse.

Long-Acting Muscarinic Antagonists (LAMA)

If inhaled corticosteroids alone do not control asthma, a health care provider may add a long-acting bronchodilator such as a long-acting beta2-agonist (LABA) or a LAMA.

  • For children under 12 and most people 12 or older with asthma that is not controlled by an inhaled corticosteroid alone, adding a LABA rather than a LAMA to an inhaled corticosteroid is preferred.
  • For people 12 years old and older, if a LABA cannot be used, a LAMA may be used with inhaled corticosteroid treatment instead of continuing the inhaled corticosteroid alone.
  • For people 12 years old and older whose asthma is not controlled with an inhaled corticosteroid plus a LABA, adding a LAMA is recommended.

Indoor Allergen Reduction

  • For people with asthma who are sensitive to indoor substances (such as house dust mites), using multiple strategies to reduce the allergen is recommended (such as air purifiers, HEPA vacuum cleaners and pillow and mattress covers that prevent dust mites from going through them). Using only one strategy often does not improve asthma outcomes.  
  • Integrated pest management is recommended for those who are allergic and exposed to cockroaches, mice or rats.
  • These strategies are not recommended for people who are not allergic to indoor substances.

Immunotherapy

Immunotherapy is an asthma management strategy in which people with allergies are exposed to low doses of an allergen.

  • Allergy shots, known as subcutaneous immunotherapy, are recommended for people who have allergic asthma and whose symptoms worsen after exposure to certain allergens.
  • Sublingual immunotherapy, which involves placing drops or tablets containing allergens under the tongue, is not recommended for the treatment of allergic asthma.

Fractional Exhaled Nitric Oxide (FeNO) Testing

FeNO tests measure the amount of nitric oxide, a byproduct of inflammation, in the air you breathe out.

  • FeNO testing in people ages 5 and older is recommended when either the diagnosis or the approach to therapy is uncertain.
  • FeNO testing should not be used alone to assess asthma control or predict the clinical course of disease.
  • In children ages 4 years and younger who have recurrent episodes of wheezing, FeNO measurement does not reliably predict the future development of asthma.

Bronchial Thermoplasty

Bronchial thermoplasty is an FDA-approved medical procedure that treats severe, persistent asthma. It uses heat to reduce the smooth muscle around the airways that tighten during asthma attacks and makes it hard to breathe.

  • Most people ages 18 years and older with uncontrolled, moderate to severe persistent asthma should not undergo bronchial thermoplasty because the benefits are small, the risks are moderate, and the long-term outcomes are uncertain.
  • Some people with moderate to severe persistent asthma who have troublesome symptoms may be willing to accept the risks of bronchial thermoplasty and might choose this intervention after shared decision making with their health care provider.