Beyond the blue inhaler: How nurses can champion the move to SABA-free asthma care

Senior respiratory nurse specialist Helena Cummings explains current recommended inhaler treatment regimens for asthma, including the move away from short-acting beta agonist (SABA)-only treatment, and overall shift to SABA-free care, and how nurses can embed these regimens in practice

Asthma has undergone quite the revolution in recent years. Publication of the collaborative British Thoracic Society (BTS), NICE and Scottish Intercollegiate Guidelines Network (SIGN) guideline on asthma in late 2024 felt like a huge leap for the UK.

This guideline emphasises that no matter the age, all patients with asthma receive an inhaled corticosteroid (ICS) containing regimen from diagnosis, ensuring airway inflammation is addressed early and that no patient should be prescribed short-acting beta agonist (SABA) only treatment.

This means that UK practice now aligns with the evidence – and global expert consensus – that asthma is, at its core, an inflammatory disease. We have moved away from accepting over-reliance on blue relievers. Now, inflammation is rightly recognised as sitting at the very heart of asthma management. For nurses in every setting, from the emergency department through to community and specialists in tertiary care, this shift represents both a challenge and an exciting opportunity to ensure asthma management is right from the very beginning.

What do the BTS/NICE/SIGN guidelines say about AIR and MART from diagnosis?

For decades, people with asthma have relied on SABA inhalers for symptom relief, often without essential ICS alongside. While SABA offer rapid relief of bronchospasm, frequent use without anti-inflammatory protection significantly increases asthma exacerbation risk and, tragically, preventable asthma-related deaths. This was detailed in the National Review of Asthma Deaths (NRAD), which over a decade ago highlighted the dangers of SABA overuse, and the underuse of ICS therapy. This is not just theoretical. In Humber and North Yorkshire, two adolescents recently and tragically lost their lives to asthma, with SABA over-reliance identified as a significant contributing factor in each case. These losses stand as a powerful reminder of the dangers of SABA overuse without addressing the underlying inflammation.

Thankfully, the 2024 BTS/NICE/SIGN guidance provides a definitive shift away from SABA-only treatment, recommending that, regardless of age, all patients with asthma begin an ICS-containing regimen from diagnosis. The guideline acknowledges the challenges of obtaining objective evidence of asthma in children under five; however, where there is a strong clinical history, ICS treatment should not be delayed. Remember, ICS-containing therapies treat the cause of asthma (inflammation), yet SABA only treats the consequence. This underpins the uncompromising focus on early anti-inflammatory treatment for all ages within the guidance.

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At the centre of the guidelines are ICS–formoterol combination inhalers, which (dependent on drug licensing) can be used for both asthma maintenance and symptom relief. When used only as needed, this is known as Anti-Inflammatory Reliever (AIR) therapy; when used daily both for maintenance and as needed for relief, it becomes Maintenance and Reliever Therapy (MART).

For children aged 5 to 11 years, the BTS/NICE/SIGN guidance maintains a clear, stepwise approach. It advises starting with a paediatric low-dose ICS twice daily, with a SABA as needed for symptom relief. If control remains poor, a low-dose MART regimen can be considered, provided the child can safely manage it. Since the publication of the guidance, Symbicort 100/6 Turbohaler has gained a licence for children aged six years and over. At the time of writing, it remains the only inhaler with a paediatric MART licence for those under 12 but helps to put this recommendation into practice.

For adults and adolescents aged 12 years and over, both low-dose AIR and MART can be used from diagnosis. For most you will start with low-dose AIR for symptom relief, but if you have a patient who is highly symptomatic, begin with low-dose MART alongside management of acute symptoms as needed. Once control is achieved, you can consider stepping down to as-needed AIR therapy.

How should nurses approach stepping up or stepping down treatment with AIR and MART?

After the initial treatment steps, the guidance champions a flexible, patient-centred approach that in my experience fits with how people with asthma use their inhalers day to day. A useful way to understand AIR and MART is to picture formoterol, the fast and long-acting bronchodilator within these inhalers, as a vehicle that carries ICS directly to the airways. When asthma symptoms flare and a patient instinctively reaches for quick relief, formoterol offers the rapid bronchodilation they trust and expect. Within that same moment (because the ICS is also built into the one inhaler) the anti-inflammatory treatment is delivered automatically. This is the real power of AIR and MART – these regimens ensure the fast relief that our patients want and need, while delivering the anti-inflammatory treatment that is essential to asthma control. It’s a simple, yet very effective approach that naturally revs up when control is slipping and eases off when symptoms settle, ensuring patients get the right treatment at the right time, without unnecessary complexity.

Where can nurses find the most up-to-date resources on inhaler licensing?

It is worth remembering that licensed indications for asthma inhalers can vary between medicines, doses and even devices. Not every inhaler is licensed exactly in line with BTS/NICE/SIGN 2024 guidance. As nurses, we have a duty to check the details carefully. You can verify product licences using trusted resources such as the electronic Medicines Compendium (eMC), BNF online and Rightbreathe.

Table 1 below provides a useful list of inhalers in the UK that are licensed for AIR and/or MART therapy, with their age-specifications (as of December 2025).

Table 1. Inhalers licensed for AIR and/or MART therapy

Related Article: Research backs use of combination inhaler for mild asthma in children

It is also good practice to link in with your local respiratory team, medicines optimisation pharmacist, or formulary committee to confirm which inhalers are licensed, recommended, and available locally. If your local guidance hasn’t yet caught up with the national recommendations, now is the time to act. Change begins with us, all of us, whether we work in primary care, hospitals, community settings, or beyond. Together, we can build a movement that drives the implementation of this guidance and ensures every person with asthma receives the care they deserve.

Why does inhaler technique matter for nurses?

When it comes to inhalers, good asthma care is reliant on more than the medicines prescribed. It heavily depends on the patient’s ability to take their inhaled devices correctly. As nurses we play a crucial role in ensuring the correct inhaler technique through effective communication, empowerment and training. Even the most effective of drugs can only work if taken correctly, and as the saying goes ‘the most expensive inhaler is the one the patient can’t or won’t use’.

Empowering patients starts with clear, confident communication. Nurses should understand how different inhalers and the drugs within them work so that they can explain this simply to patients. When patients understand why they use a device their adherence and use will improve.

Language matters, for example patients moving to a SABA free regimen (AIR/MART) may feel anxious at the thought of not having a ‘blue inhaler’. Statements like ‘I’m removing your SABA’ will fill them with dread. Instead, frame change as an upgrade that enhances safety and control, much like upgrading your iPhone to a newer model (other mobile providers are available).

By combining clinical knowledge with empathetic education, nurses can help patients believe in their treatment, use inhalers correctly, and achieve sustainable asthma control.

The resources listed below provide clear visual and written demonstrations of device specific technique whether that means a slow, steady inhalation for pressurised metered-dose inhalers (pMDIs) and soft mist inhalers, or a fast, deep inhalation for dry powder inhalers (DPIs). Incorporating these tools into routine reviews supports consistent, evidence-based teaching and will support your patients in gaining suitable asthma control.

Key points

• ICS containing regimens are important for all patients with a diagnosis of asthma.
• Prescribing SABA alone is outdated care which exposes patients to avoidable harm.
• The BTS/NICE/SIGN 2024 guidance advocates the shift to SABA-free approaches such as AIR and MART and is a critical step in safeguarding our patients from the very start of their asthma journey.
• It is essential that uncontrolled asthma is identified early, treatment is optimised in line with local and national guidance, and specialist referral is made without delay if required.

Helena Cummings is a Senior Respiratory Nurse Specialist and Severe Asthma Lead Nurse at NHS Humber Health Partnership

Related Article: Quick quiz: Asthma/COPD overlap syndrome (ACOS)

Useful resources

• Asthma + Lung UK: patient-friendly videos, guides and printable inhaler checklists. Available at: www.asthmaandlung.org.uk
• RightBreathe: device specific videos, comparisons, and prescribing information. Available at: www.rightbreathe.com
• UK Inhaler Group Compendium: national standards and inhaler technique videos. Available at: www.ukinhalergroup.co.uk
• Primary Care Respiratory Society (PCRS): clinical updates and best-practice resources for respiratory clinicians. Available at: www.pcrs-uk.org

Sources and further information

• Beasley R et al. The potential benefit of titrating additional ICS through the vehicle of bronchodilator reliever use. J Allergy Clin Immunol Pract 2023;11(6):1633-35
• Electronic Medicines Compendium (eMC). BIBECFO 100/6 micrograms per actuation pressurised inhalation solution – Summary of Product Characteristics (SmPC).
• eMC. Fobumix Easyhaler 80/4.5 inhalation powder – SmPC.
• eMC. Fobumix Easyhaler 160/4.5 inhalation powder – SmPC.
• eMC. Fostair 100/6 micrograms per actuation pressurised inhalation solution – SmPC.
• eMC. Fostair NEXThaler 100 micrograms/6 micrograms per actuation inhalation powder – SmPC.
• eMC.. Luforbec 200/6 micrograms per actuation pressurised inhalation solution – SmPC.
• eMC. Proxor 100/6 microgram per actuation pressurised inhalation solution – SmPC
• eMC. DuoResp Spiromax 160 micrograms / 4.5 micrograms inhalation powder – SmPC.
• eMC. Symbicort, 100 micrograms/3 micrograms/actuation pressurised inhalation SmPC.
• eMC. Symbicort Turbohaler 200/6 Inhalation powder – SmPC.
• eMC. WockAIR 160 micrograms/4.5 micrograms inhalation powder – SmPC.
• Nwaru B et al. Overuse of short-acting β₂-agonists in asthma is associated with increased risk of exacerbation and mortality: a nationwide cohort study of the global SABINA programme. Eur Respir J 2020;55(4):1901872
• NICE. Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN). [NG245] November 2024
• PCRS. Tailoring Inhaler Devices. 2024
• Royal College of Physicians. Why asthma still kills. The National Review of Asthma Deaths (NRAD). 2014