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pulm.asthma.core.v1PRODUCTION
pulm.asthma.core.v1

Asthma (chronic stepwise + acute exacerbation)

pulmonologychronicacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm asthma diagnosis (variable airflow obstruction with reversibility) vs ACO/COPD/VCD/EILO (GINA 2026 Box 1-2)

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Advance rule
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Advance when

Diagnosis confirmed by spirometry + symptom pattern per GINA 2026

Patient inputs (19)

Adult vs pediatric pathway and biologic eligibility (GINA 2026 age-stratified steps)

Acute severity gate; admission threshold SpO2 <92% per BTS/SIGN 2024; ICU criteria

Tachypnea + accessory muscles for severe exacerbation (BTS/SIGN 2024 severity table)

Tachycardia, pulsus paradoxus pattern, β2-agonist toxicity (BTS/SIGN 2024)

Step-up trigger; biologic eligibility ≥2 OCS courses/yr (GINA 2026 Step 5; ATS/ERS 2024 severe asthma)

Technique/adherence assessed BEFORE step-up per GINA 2026

GINA: avoid LTRA boxed-warning use; prefer ICS-formoterol; manage flares aggressively

Detect SABA-only / NSAID-AERD / β-blocker / ACE-I cough — adjust (GINA 2026 §3 risk factors)

FEV1, FEV1/FVC, reversibility — diagnosis confirmation (GINA 2026 Box 1-2; ATS/ERS 2022)

PEF % personal best — drives severity tier and zone of action plan (GINA 2026 Box 4-1; BTS/SIGN 2024)

Occupational asthma + trigger control (GINA 2026 §3; NICE 2024 NG80)

T2 phenotype — biologic selection: ≥150 dupilumab (QUEST, Castro NEJM 2018); ≥300 anti-IL5/anti-IL5R (MENSA, Ortega NEJM 2014)

T2 inflammation marker; dupilumab response predictor (ATS/ERS 2024; GINA 2026 Box 3-4)

Omalizumab eligibility 30–700 IU/mL with perennial allergen (INNOVATE; GINA 2026 Step 5)

Severe exac: rule out pneumothorax, pneumonia, foreign body (BTS/SIGN 2024)

Severe exac: rising / normalising PaCO2 = impending respiratory failure (BTS/SIGN 2024 life-threatening criteria)

Monitor for hypokalemia after high-dose β2-agonist — continuous neb / IV (BTS/SIGN 2024 acute management)

High-dose β2-agonist → β2-mediated lactic acidosis mimics sepsis (Lau CI Emerg Med J 2015)

Hyperglycemia from systemic steroids + β2-agonist (BTS/SIGN 2024 monitoring)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateningsilent_chest_or_AMS_or_exhaustion
    Silent chest, altered mental status, exhaustion, or pulsus paradoxus >25 mmHg (BTS/SIGN 2024 life-threatening criteria)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrising_or_normalising_paco2
    PaCO2 rising or normalising in tachypnoeic severe asthma — PaCO2 should be LOW from hyperventilation (BTS/SIGN 2024 near-fatal criteria)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepef_under_50_after_first_hour
    PEF <50% personal best after first-hour SABA + ipratropium + systemic steroid (BTS/SIGN 2024 severe criteria)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_severe_exacerbation
    Severe exacerbation in pregnant patient (GINA 2026 §3 pregnancy)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredifferential_acute_wheeze_vs_mimics
    Acute severe wheeze — is it asthma or a mimic? §5.5.2 acute differential: anaphylaxis (urticaria/angioedema/hypotension + exposure + tryptase) → epinephrine NOW; tension/simple pneumothorax (sudden pleuritic + unilateral ↓breath sounds, CXR/POCUS); PE (disproportionate hypoxia, pleuritic, VTE risk, no sputum change → Wells/D-dimer/CTPA); ADHF/cardiac asthma (orthopnea/JVD/S3/NT-proBNP↑↑/echo/CXR edema); foreign body (sudden onset, focal monophonic wheeze, asymmetric exam — bronchoscopy)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehypokalemia_after_beta2
    K+ <3.5 after high-dose / continuous β2-agonist (BTS/SIGN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatelactic_acidosis_after_beta2
    Unexplained AGMA / lactate >2 in severe asthma exac without sepsis (Lau CI Emerg Med J 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedifferential_asthma_vs_mimics_chronic
    Chronic wheeze/dyspnea not clearly asthma — §5.5.2 pivots with test characteristics: post-BD spirometry reversibility ≥12% AND ≥200 mL = asthma vs fixed FEV1/FVC <0.70 = COPD; FeNO ≥25 ppb (≥50 high) = T2 inflammation; blood eos ≥150/≥300 = eosinophilic/biologic-eligible; methacholine PC20 <8 mg/mL = airway hyperresponsiveness (high NPV when negative); truncated INSPIRATORY flow-volume loop + normal spirometry → VCD/EILO (laryngoscopy gold standard); normal spirometry + ABG hypocapnia + Nijmegen → hyperventilation; eos >1500 + ANCA + mono/multineuritis → EGPA; Aspergillus sIgE/IgG + central bronchiectasis + total IgE >1000 → ABPA; NSAID reaction + nasal polyps → AERD; NT-proBNP↑↑ + orthopnea + echo LV dysfunction → cardiac asthma/HF; cross-shift PEF drop work-related → occupational (GINA 2026 §2/§5)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatebiologic_eligibility_phenotype_chain
    Step-5 severe asthma biologic selection — phenotype→biomarker→agent decision chain: total IgE 30–700 IU/mL + perennial allergen → omalizumab (INNOVATE); blood eos ≥300 → mepolizumab/benralizumab (MENSA/SIROCCO/CALIMA); eos ≥150 OR FeNO ≥25 OR OCS-dependent → dupilumab (QUEST/VENTURE; also AD/CRSwNP); any severe asthma incl. eos <150 AND FeNO <25 → tezepelumab (NAVIGATOR); OCS-dependent → mepolizumab/benralizumab/dupilumab proven OCS-sparing (SIRIUS/ZONDA/VENTURE)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

GINA 2026 Track 1 — ICS-formoterol-based stepwise (Steps 1–5)
axis: gina_track1_stepwisestep 1 - Step 1 — Symptoms <2x/month
Selected step "Step 1 — Symptoms <2x/month" — Symptoms <2x/month, no waking from asthma in last month, no risk factors for exacerbation (GINA 2026 Step 1)
  • budesonide-formoterol
    first line
    ICS_formoterol_reliever
    200/6 µg • inhaled • 1 puff PRN for symptoms (max: 12 puffs/day total)
    triggers: symptoms_present
    GINA 2026 Track 1 AIR — replaces SABA-only. SYGMA-1 (PMID 29768149): as-needed budesonide-formoterol superior to as-needed SABA for severe exacerbations; SYGMA-2 (PMID 29768147): as-needed bud-form non-inferior to maintenance budesonide for severe exac at ≈1/4 the inhaled steroid dose; Novel START (PMID 31112386): bud-form lower severe-exac risk vs SABA. RxCUI 1246304 = budesonide/formoterol SCD (RxNav-validated 2026-05-24)
    rxcui 1246304

outpatient playbook — drug actions (4)

  1. 1. budesonide-formoterol
    200/6 µg • inhaled • 1 puff PRN (Step 1) → 1 BID + PRN (Step 3) → 1 BID 400/12 (Step 4)
    trigger: GINA step assignment
    GINA 2026 Track 1 backbone
  2. 2. tiotropium
    2.5 µg Respimat • inhaled • 2 puffs once daily
    trigger: Inadequate control on medium-dose ICS-formoterol (Step 4 add-on)
    GINA 2026 Step 4-5 add-on
  3. 3. biologic referral (omalizumab / mepolizumab / benralizumab / dupilumab / tezepelumab)
    Per agent; weight + IgE for omalizumab • SC • q2–8 weeks per agent
    trigger: Severe asthma at Step 5 with phenotype-matching biomarker
    ATS/ERS 2024
  4. 4. prednisone
    40–50 mg • PO • daily × 5–7 days
    trigger: Outpatient exacerbation not responding to reliever increase
    GINA 2026 self-management plan

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Episodic wheeze, cough, chest tightness, dyspnea (GINA 2026 Box 1-2); Nocturnal awakening from cough/wheeze (GINA 2026 control assessment); Severe acute exacerbation (PEF <50%, accessory muscles, silent chest) — BTS/SIGN 2024 severity classification.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Asthma (chronic stepwise + acute exacerbation)** (pulm.asthma.core.v1).
Phenotype framing: §5.5.2 differential-as-data — asthma vs COPD/ACO (post-BD FEV1/FVC fixed <0.70 = COPD; BDR ≥12% AND ≥200 mL = asthma), vs VCD/EILO (inspiratory truncated flow-volume loop, laryngoscopy gold standard), vs hyperventilation (normal spirometry, ABG hypocapnia, Nijmegen), vs EGPA (eos >1500, ANCA, multisystem), vs AERD/Samter (NSAID reaction + nasal polyps), vs ABPA (Aspergillus IgE/IgG, central bronchiectasis, eos), vs cardiac asthma/ADHF (NT-proBNP↑↑, orthopnea, echo), vs occupational (cross-shift PEF, work-related pattern); phenotype assigned (allergic / eosinophilic / AERD / occupational / EIB) per GINA 2026 §2
Scope: Confirm asthma diagnosis (variable airflow obstruction with reversibility) vs ACO/COPD/VCD/EILO (GINA 2026 Box 1-2)

No severity triggers fired against current inputs.

Plan

Regimen axis: **GINA 2026 Track 1 — ICS-formoterol-based stepwise (Steps 1–5)** — step "Step 1 — Symptoms <2x/month".
1. budesonide-formoterol 200/6 µg inhaled 1 puff PRN for symptoms (ICS_formoterol_reliever, first line) — GINA 2026 Track 1 AIR — replaces SABA-only. SYGMA-1 (PMID 29768149): as-needed budesonide-formoterol superior to as-needed SABA for severe exacerbations; SYGMA-2 (PMID 29768147): as-needed bud-form non-inferior to maintenance budesonide for severe exac at ≈1/4 the inhaled steroid dose; Novel START (PMID 31112386): bud-form lower severe-exac risk vs SABA. RxCUI 1246304 = budesonide/formoterol SCD (RxNav-validated 2026-05-24)

Setting playbook (outpatient) — Achieve and maintain symptom control + reduce future exacerbation risk via lowest effective GINA 2026 step
2. budesonide-formoterol 200/6 µg inhaled 1 puff PRN (Step 1) → 1 BID + PRN (Step 3) → 1 BID 400/12 (Step 4) — GINA step assignment (GINA 2026 Track 1 backbone)
3. tiotropium 2.5 µg Respimat inhaled 2 puffs once daily — Inadequate control on medium-dose ICS-formoterol (Step 4 add-on) (GINA 2026 Step 4-5 add-on)
4. biologic referral (omalizumab / mepolizumab / benralizumab / dupilumab / tezepelumab) Per agent; weight + IgE for omalizumab SC q2–8 weeks per agent — Severe asthma at Step 5 with phenotype-matching biomarker (ATS/ERS 2024)
5. prednisone 40–50 mg PO daily × 5–7 days — Outpatient exacerbation not responding to reliever increase (GINA 2026 self-management plan)

Non-pharmacologic actions:
- Written asthma action plan — green/yellow/red zones (GINA 2026 Box 4-2)
- Inhaler technique training + 3-month re-audit (GINA 2026 §3)
- Allergen avoidance counselling (GINA 2026 §3; NICE 2024 NG80)
- Smoking cessation pharmacotherapy if applicable (GINA 2026 §3)
- Annual influenza vaccination (ACIP 2026; GINA 2026)
- Pulmonary rehab referral if ≥1 hospitalisation or significant deconditioning (BTS/SIGN 2024)

AVOID / contraindication checks:
- Beta_blocker_avoid_nonselective_in_asthma_cardioselective_OK_if_strong_CV_indication (GINA 2026 §3)
- Nsaid_aspirin_avoid_all_COX1_in_AERD_unless_desensitised (GINA 2026 §3; NAEPP EPR 4 2020)
- Macrolide_qt_check_before_chronic_azithro (ATS/ERS 2024)
- LTRA_neuropsychiatric_warning_counsel_and_monitor (FDA 2020 boxed warning; GINA 2026)
- High_dose_OCS_minimise_bone_glycaemia_adrenal_axis_screen_on_taper (GINA 2026 §3; ATS/ERS 2024)
- Pregnancy_continue_ICS_LABA_do_not_step_down_treat_exacerbations_aggressively (GINA 2026 §3 pregnancy; NAEPP EPR 4 2020)
- Smoker_ACO_never_SABA_only_ICS_containing_regimen_mandatory (GINA 2026 §5; GOLD 2026)
- Biologic_eligibility_gate_by_phenotype_IgE_eos_FeNO_OCS_before_initiation (ATS/ERS 2024; GINA 2026 Step 5)

Monitoring

Regimen monitoring:
- PEF q visit and at-home diary; ≥20% diurnal variability supports asthma (GINA 2026 §4)
- ACT score (calc.act) q visit — <20 = uncontrolled step-up trigger; ≥20 sustained 3 mo = step-down candidate (GINA 2026 Box 2-2)
- Inhaler technique + adherence q visit BEFORE any step-up (GINA 2026 §3)
- Blood eos + FeNO before/at biologic initiation and to track T2 phenotype (ATS/ERS 2024)
- K+ q4h during continuous neb (β2-agonist drives hypokalemia) (BTS/SIGN 2024)
- Lactate if continuous neb or unexplained AGMA — β2-mediated lactic acidosis mimics sepsis (BTS/SIGN 2024)
- Biologic response at 4 months — ≥50% exacerbation reduction / OCS reduction = responder (ATS/ERS 2024)
- Adrenal-axis screen during maintenance-OCS taper after biologic response (ATS/ERS 2024)
- Attempt step-down after ≥3 months sustained control; biologic step-down only after ≥12 mo control + OCS-free with relapse plan (GINA 2026 §4; ATS/ERS 2024)

Setting (outpatient) monitoring:
- ACT/control review at 4–6 weeks after step change (GINA 2026 §4)
- Annual review including spirometry (GINA 2026 §4; NICE 2024 NG80)
- Biologic response at 4 months — ≥50% exacerbation reduction (ATS/ERS 2024)
- Attempt step-down after ≥3 months sustained control (GINA 2026 §4)

Follow-up plan: Written asthma action plan (GINA 2026 Box 4-2), vaccinations — flu, pneumococcal, COVID, RSV (ACIP 2026), smoking cessation, weight, allergen control, controller refill, technique re-audit, follow-up within 1 week of any ED/admission per GINA 2026
- Close-out criterion: Action plan + vaccinations + 1-week follow-up complete

Monitoring phase: Acute: hourly PEF, RR, SpO2; K+/lactate after continuous neb; VBG q1-2h if hypercapnic (BTS/SIGN 2024). Chronic: ACT/exacerbation review at 4–6 weeks; biologic response at 4 months per ATS/ERS 2024; step-down attempt after 3 months controlled (GINA 2026 §4)

Disposition

Current setting: outpatient — Achieve and maintain symptom control + reduce future exacerbation risk via lowest effective GINA 2026 step

Disposition criteria:
- Continue current step if controlled (GINA 2026 §4)
- Step up if uncontrolled with verified technique + adherence (GINA 2026 §4)
- Refer to severe-asthma clinic if at Step 5 with ongoing exacerbations (ATS/ERS 2024)

Escalation triggers (move to higher acuity):
- Acute severe exacerbation → ED (BTS/SIGN 2024)
- Step ≥4 with ≥2 OCS courses/year → severe-asthma clinic (ATS/ERS 2024)
- Hypoxaemia SpO2 <92% → ED (BTS/SIGN 2024)

Patient Action Plan

**Asthma action plan (GINA-aligned)**
Personalised values: personal_best_PEF, controller_inhaler, reliever_inhaler, OCS_dose_for_emergency.

**Doing well — PEF 80–100% personal best** (green):
Triggers:
- No cough, wheeze, chest tightness, or shortness of breath (GINA 2026 Box 4-2 green zone)
- Can do all usual activities (GINA 2026 control criteria)
- No night waking from asthma (GINA 2026 control criteria)
- PEF ≥80% personal best (GINA 2026 Box 4-2)
Actions:
- Take controller as prescribed every day — do not skip even if feeling well (GINA 2026 §3)
- Use reliever (ICS-formoterol or SABA) only as needed (GINA 2026 Track 1)
- Continue trigger avoidance (GINA 2026 §3)
- Keep follow-up appointments (GINA 2026 §4)

**Caution — PEF 50–79% personal best OR symptoms increasing** (yellow):
Triggers:
- Cough, wheeze, chest tightness, or breathlessness (GINA 2026 Box 4-2 yellow zone)
- Waking at night with asthma (GINA 2026 control assessment)
- Reliever needed more than usual (GINA 2026 Box 4-2)
- PEF 50–79% personal best (GINA 2026 Box 4-2)
Actions:
- Increase ICS-formoterol PRN reliever as needed — max 12 puffs/day total (GINA 2026 Track 1)
- If on MART: continue maintenance + use additional puffs as reliever (GINA 2026 MART protocol)
- If not improving in 24–48 h or worsening: start prednisone 40–50 mg PO daily x 5–7 days per pre-prescribed action plan (GINA 2026 Box 4-2)
- Contact your provider within 24 h (GINA 2026 Box 4-2)
Contact provider when:
- Symptoms not improving after 48 h of increased reliever (GINA 2026 Box 4-2)
- Any decline in PEF below 50% best (GINA 2026 yellow→red zone boundary)
- Need to use reliever more often than every 4 h (GINA 2026)

**Medical alert — PEF <50% personal best OR severe symptoms** (red):
Triggers:
- Very short of breath, cannot speak in full sentences (BTS/SIGN 2024 severe criteria)
- Reliever not helping (GINA 2026 Box 4-2 red zone)
- PEF <50% personal best (GINA 2026 Box 4-2 red zone)
- Lips or fingertips blue — cyanosis (BTS/SIGN 2024 life-threatening criteria)
- Confusion or extreme drowsiness (BTS/SIGN 2024 life-threatening criteria)
Actions:
- Use reliever right now — ICS-formoterol 4 puffs OR SABA 4–8 puffs — repeat every 20 min while seeking help (GINA 2026 Box 4-2)
- Take prednisone 40–50 mg PO now if available (GINA 2026 Box 4-2)
- Call 911 / emergency services immediately (GINA 2026 Box 4-2)
- Sit upright; do not lie down (BTS/SIGN 2024)
Contact provider when:
- Any red zone symptom — go to ED now, do not wait (GINA 2026 Box 4-2)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Silent chest, altered mental status, exhaustion, or pulsus paradoxus >25 mmHg (BTS/SIGN 2024 life-threatening criteria)
- [LIFE_THREATENING] PaCO2 rising or normalising in tachypnoeic severe asthma — PaCO2 should be LOW from hyperventilation (BTS/SIGN 2024 near-fatal criteria)
- [SEVERE] PEF <50% personal best after first-hour SABA + ipratropium + systemic steroid (BTS/SIGN 2024 severe criteria)

Citations

- GINA 2026 Strategy Report (released May 2026) + ATS/ERS 2024 Severe Asthma Guidelines + NAEPP 2020 Focused Update + BTS/SIGN 2024 [PMID:29768149](https://pubmed.ncbi.nlm.nih.gov/29768149/)
- Cited evidence (PMID 29768147) [PMID:29768147](https://pubmed.ncbi.nlm.nih.gov/29768147/)
- Cited evidence (PMID 31112386) [PMID:31112386](https://pubmed.ncbi.nlm.nih.gov/31112386/)
- Cited evidence (PMID 31451207) [PMID:31451207](https://pubmed.ncbi.nlm.nih.gov/31451207/)
- Cited evidence (PMID 23633340) [PMID:23633340](https://pubmed.ncbi.nlm.nih.gov/23633340/)

Last reconciled with current guidelines: 2026-05-26.
References
  • GINA 2026 Strategy Report (released May 2026) + ATS/ERS 2024 Severe Asthma Guidelines + NAEPP 2020 Focused Update + BTS/SIGN 2024 — PMID:29768149
  • Cited evidence (PMID 29768147) — PMID:29768147
  • Cited evidence (PMID 31112386) — PMID:31112386
  • Cited evidence (PMID 31451207) — PMID:31451207
  • Cited evidence (PMID 23633340) — PMID:23633340