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 39, 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 beta2agonist, 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).