Get emergency help now if a person with asthma cannot speak in sentences, drink or lie down because of breathlessness, has a quiet or "silent" chest, has blue or grey lips, or becomes drowsy or confused. Call your local emergency number and use the reliever inhaler while waiting, as set out in the asthma action plan.
Key points
- Asthma attacks often rise in the weeks after children return to school from the long summer break. Viral colds caught at school are the main suspected trigger, and late-summer and autumn pollens such as ragweed add to it.
- Allergic rhinitis (hay fever) is very common in people with asthma. GINA advises treating it with an intranasal corticosteroid alongside asthma treatment.
- GINA 2026 says adults, adolescents and children aged 6 to 11 should not be treated with a short-acting reliever (SABA) alone. Everyone with asthma needs treatment that contains an inhaled corticosteroid (ICS).
- For adults and adolescents, GINA's preferred reliever is low-dose ICS-formoterol taken as needed, because it reduces severe attacks compared with a SABA reliever.
- Every person with asthma should have a written, digital or pictorial action plan that says what to take when asthma worsens and when to get medical help.
Why flares cluster after the return to school
GINA describes an asthma exacerbation (flare-up or attack) as a sudden or gradual worsening of breathlessness, cough, wheeze or chest tightness, and of lung function, compared with the person's usual state. Attacks are usually triggered by a viral upper respiratory infection, by pollen or air pollution, or by not taking inhaled corticosteroid regularly. They can also happen without any of these, and severe attacks can be fatal even in people whose symptoms are normally infrequent.
A Canadian study of asthma hospital admissions from 1990 to 2002 found a sharp "September epidemic" every year. Admissions of school-age children peaked on average about 18 days after school restarted, followed by smaller peaks in preschool children and then in adults. The authors concluded that school-age children probably carry the viruses responsible home to their families, and that asthma control should be improved before the return to school. The same pattern can be expected wherever a long school holiday ends, which in the southern hemisphere is early in the calendar year rather than in September.
Other factors add to the risk at this time of year:
- Missed preventer doses over the holidays. GINA lists inadequate ICS (none, poor adherence or poor inhaler technique) as a key risk factor for attacks.
- Autumn pollen: ragweed and other late-blooming plants release pollen in late summer and early fall (MedlinePlus). Which pollens matter varies by region.
- Other respiratory viruses such as influenza, COVID-19 and RSV. GINA advises vaccination against them according to local advice.
The link between the nose and the lungs
Allergic rhinitis causes sneezing, a runny or blocked nose, itchy nose, eyes and throat, and watery eyes soon after exposure to an allergen such as pollen, dust mite or animal dander. Later effects include nasal congestion, cough, blocked ears, reduced smell, tiredness and irritability. It runs in families. WHO notes that asthma is more likely in people with other allergic conditions such as eczema and rhinitis.
GINA lists rhinitis among the conditions to look for when asthma is hard to control, and recommends treating allergic rhinitis with an intranasal corticosteroid as well as treating the asthma. It notes that treating the nose reduces nasal symptoms but may not by itself improve asthma control, so asthma treatment must not be neglected. Chronic rhinosinusitis, especially with nasal polyps, is linked to more severe asthma.
MedlinePlus describes nasal corticosteroid sprays as the most effective treatment for allergic rhinitis, working best when used continuously. Antihistamines suit symptoms that are occasional or short-lived. Decongestant nasal sprays should not be used for more than 3 days. Saline rinses can help mild symptoms. Allergen immunotherapy, by injection or as tablets under the tongue, is an option when symptoms are hard to control.
How GINA 2026 approaches asthma treatment
- No SABA-only treatment. Most people with asthma have airway inflammation even when symptoms are infrequent. GINA links SABA-only treatment with more attacks, worse lung function and a higher risk of death from asthma. Using 3 or more 200-dose SABA canisters a year is linked to more severe attacks, and 12 or more a year to a higher risk of death.
- Track 1 (preferred, adults and adolescents): low-dose ICS-formoterol as the reliever, taken whenever needed, either alone for mild asthma or with regular ICS-formoterol maintenance (maintenance-and-reliever therapy, MART). In trials this reduced emergency visits or hospital admissions by about two-thirds compared with SABA alone.
- Track 2 (alternative): an ICS-SABA combination reliever, or a SABA reliever with a regular ICS-containing preventer. It is used when Track 1 is not available or suitable, with close attention to adherence to avoid SABA-only use.
- Children 6 to 11: all should receive ICS-containing treatment. In mild asthma, as-needed low-dose ICS-formoterol reduces attacks compared with SABA alone. Treatment for children aged 5 and under is covered separately in the full GINA report.
- Check before stepping up: watch the person use the inhaler, discuss adherence, and look for triggers such as smoking, vaping, beta-blockers, NSAIDs (in aspirin-sensitive asthma), allergen exposure and untreated rhinitis.
Montelukast (a leukotriene receptor antagonist) is an alternative option in some steps. GINA advises prescribers to note concerns about possible neuropsychiatric side effects.
Preparing for the school term
- Restart or continue the preventer every day before term starts, and check inhaler technique, ideally with a spacer for pressurised inhalers in children.
- Update the written action plan and give a copy, with a reliever and spacer, to the school.
- Keep up to date with vaccines recommended locally for the person's age, including influenza, COVID-19, pneumococcal, pertussis and RSV, as GINA advises.
- Keep taking ICS during a cold. GINA advises continuing prescribed asthma medicines during respiratory infections.
- On high-pollen days, keep windows closed and save outdoor activities for later in the day or after rain.
- Avoid smoking and vaping, and keep homes and cars used by children smoke-free.
Red flags / when to get urgent help
GINA's action-plan advice is to get medical care if symptoms are getting worse quickly or not improving after 2 to 3 days, and also:
- on ICS-formoterol reliever: more than 12 inhalations in 24 hours in total
- on ICS-SABA reliever: needing it more than 6 times in a day
- on SABA reliever: needing it again within 3 hours
Signs of a severe or life-threatening attack that need emergency care include:
- unable to speak in sentences, drink or lie down
- breathing faster than 30 breaths a minute
- a quiet or silent chest, or oxygen saturation below 92% on room air
- peak flow below 50% of personal best
- drowsiness, confusion or blue lips, which are signs of an acutely life-threatening attack
- possible anaphylaxis together with asthma (for example after a known food allergen): GINA advises giving adrenaline (epinephrine) first
People at higher risk of a fatal attack include those with a severe attack in the past year, any past intensive care admission or intubation for asthma, heavy SABA use, poor adherence to ICS, confirmed food allergy, and major psychological or social problems. After any attack, GINA advises a review within 1 week.
Frequently asked questions
Is it a cold, hay fever or an asthma attack?
Colds and hay fever both cause a runny or blocked nose. Itchy eyes and sneezing that come with pollen exposure suggest hay fever. Wheeze, chest tightness, breathlessness or night-time cough, or needing the reliever more often, mean asthma is worsening and the action plan should be followed.
Can I use only my blue reliever inhaler if my asthma is mild?
GINA advises against it. Even mild asthma carries a risk of severe attacks, and SABA-only treatment raises that risk. Ask about an ICS-formoterol reliever or a daily preventer.
Does treating hay fever help asthma?
It improves nasal symptoms and is recommended for everyone with asthma and allergic rhinitis, but GINA notes it may not improve asthma control on its own. Both conditions need treatment.
Should children use their preventer during the summer break?
Yes, if it is prescribed. Stopping over the holidays leaves the airways less protected just as school viruses begin to spread. Any reduction in treatment should be planned with the clinician.
Sources
- Global Initiative for Asthma. 2026 Summary Guide for Asthma Management and Prevention. ginasthma.org/2026-gina-summary-guide
- World Health Organization. Asthma, fact sheet. who.int
- MedlinePlus. Allergic rhinitis. medlineplus.gov
- MedlinePlus. Allergies, asthma, and pollen. medlineplus.gov
- Johnston NW, et al. The September epidemic of asthma hospitalization: school children as disease vectors. J Allergy Clin Immunol 2006. PubMed
This article is for education and does not replace advice from a doctor, nurse or pharmacist who knows the person's history. Follow your own written asthma action plan.
