Latest guidelines on asthma exacerbation management

Asthma exacerbations are a major cause of urgent healthcare use and preventable morbidity. International guidance is broadly consistent, but differences in severity classification, oxygen targets, bronchodilator delivery, escalation, and disposition can complicate practice. This targeted narrative comparative review examined the Global Initiative for Asthma (GINA) 2026 strategy, GEMA 5.5, the Australian Asthma Handbook version 3.0, the US National Asthma Education and Prevention Program Expert Panel Report 3 (EPR-3), and United Kingdom acute asthma recommendations retained in SIGN 158 and signposted through NICE pathway NG244. Official guidance was reviewed through July 2026; the 2020 NAEPP Focused Updates were also examined to contextualize continued use of EPR-3 for acute-care dosing. Recommendations were compared across severity assessment, oxygen therapy, inhaled bronchodilation, systemic corticosteroids, adjunctive treatment, reassessment, escalation, and disposition. All sources support immediate clinical assessment, prompt inhaled short-acting β2-agonist treatment, oxygen titrated for hypoxemia, early systemic corticosteroids for more than mild disease or inadequate initial response, and frequent reassessment. Ipratropium bromide is used early in moderate-to-severe or severe presentations, whereas intravenous magnesium sulfate is reserved for persistent severe or life-threatening exacerbations. Intravenous β2-agonists and aminophylline are not routine treatments, although SIGN retains narrowly defined specialist options in refractory or near-fatal disease. GINA 2026 reports limited emergency department evidence for high-dose budesonide-formoterol but calls for further study. Biologic therapy remains a long-term severe-asthma strategy rather than standard acute rescue treatment. The strongest international consensus concerns initial stabilization; meaningful variation is concentrated in oxygen targets, objective thresholds, refractory treatment, and disposition.