Tiotropium by soft-mist inhaler has been included as a new option for step 4 and 5 in patients aged >=18years with a history of exacerbations (evidence b). This treatment option for severe asthma was described in previous GINA reports, but now has been included in the stepwise treatment figure, following its regulatory approval for asthma. (box 3-5 and pp34-35)

Additional advice has been provided about management of asthma in pregnancy, including monitoring for respiratory infections, and management of asthma during labor and delivery (p.52)

The evidence level for breathing exercises has been downgraded from a to b following a review for the quality of evidence and a new meta-analisys (box 3-9, p39 and appendix chapter 6). The term “breathing exercises” is now used consistently (instead of breathing techniques) to avoid any perception that the recommendations relate to a specific technique.

Dry powder inhalers may be used to deliver short-acting beta2-agonist as an alternative to pressurized metered dose inhaler and spacer during worsening asthma or exacerbations; however, the available studies did not include patients with severe acute asthma (p63).

In primary care, patients with life-threatening or severe acute asthma should be given inhaled ipratropium bromide in addition to inhaled short-acting beta2-agonist, systemic corticosteroids, and controlled oxygen if necessary, while awaiting transfer to an acute care facility. (p 64)

A new flow-chart has been provided for management of acute asthma exacerbations or wheezing episodes in pre-school childen (p100).