Practice Guidelines

Asthma Management: Updated Guidelines from the National Heart, Lung, and Blood Institute


Am Fam Physician. 2021 Nov ;104(5):531-532.

Related editorial: Asthma Management Guidelines: Focused Updates for 2020

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• In patients 12 years and older with mild, persistent asthma, intermittent low-dose ICS and as-needed inhaled SABAs should be used as rescue therapy instead of daily controller therapy.

• In patients four years and older with moderate to severe asthma, ICS/formoterol therapy should be considered as a daily controller and rescue therapy, a SMART strategy.

• Adding an inhaled LABA to an ICS in uncontrolled asthma is preferred over adding a LAMA because of increased hospitalizations associated with LAMA therapy.

• Subcutaneous immunotherapy can reduce the severity of mild or moderate asthma over time in patients with proven allergies.

From the AFP Editors

The National Heart, Lung, and Blood Institute (NHLBI) published asthma management guidelines in 1991 and 2007. In 2020, the NHLBI released an update focusing on six priority topics.

Intermittent ICS Rescue Therapy

Intermittent use of inhaled corticosteroids (ICS) is an option for mild persistent asthma. In patients 12 years and older with mild persistent asthma, using both an ICS and a short-acting beta-agonist (SABA) as rescue therapy is equivalent to daily ICS controller therapy with SABA rescue therapy. In children younger than 12 years, the benefit of rescue ICS therapy is uncertain.

As-needed ICS therapy is also beneficial in other situations. In children up to four years of age who only experience wheezing with respiratory infections, a seven- to 10-day course of ICS daily at the start of a respiratory infection reduces exacerbations and systemic corticosteroid use. The effects of short-term ICS use on growth are uncertain, but they are likely less than systemic corticosteroids.

In patients four years and older with moderate to severe persistent asthma, a single inhaler can be used as rescue therapy. In single maintenance and reliever therapy (SMART), a combination of an ICS and the long-acting beta-agonist (LABA) formoterol can be used as a daily controller and a rescue inhaler to a maximum of eight puffs daily for

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, contributing editor.

A collection of Practice Guidelines published in AFP is available at



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