“He’s back again.”
It’s 2 am in the ED, and the 13-year-old in cubicle 4 looks familiar.
Three salbutamol nebs later, he’s improving, but his mum quietly admits they stopped the “brown inhaler” months ago.
He only uses the blue one when he feels wheezy.
For decades, paediatric asthma management has relied on two separate ideas: a preventer inhaler taken regularly and a reliever inhaler used when symptoms flare.
In reality, many children and young people are brilliant at taking the inhaler that makes them feel better immediately- and far less consistent with the one that quietly reduces airway inflammation in the background.
Enter MART.
Maintenance and Reliever Therapy (MART) is increasingly appearing in asthma guidelines, clinics, and discharge plans. The latest joint British Thoracic Society (BTS) and National Institute for Health and Care Excellence (NICE) guidance has moved MART further forward in asthma care pathways for children and young people (NICE, 2024; BTS/NICE/SIGN, 2024).
But what exactly is it, who is it for, and what does it mean for clinicians working in paediatric emergency medicine?
What is MART?
MART stands for Maintenance and Reliever Therapy.
Instead of using:
- a regular inhaled corticosteroid (ICS) preventer
- plus a separate short-acting beta agonist (SABA) reliever such as salbutamol,
the child uses one combination inhaler containing:
- an inhaled corticosteroid (ICS)
- and formoterol, a rapid-onset long-acting beta agonist (LABA)
for both everyday maintenance treatment and symptom relief.
The principle is simple: when symptoms worsen, the child automatically receives extra bronchodilation and extra anti-inflammatory treatment.
This is important because worsening asthma symptoms usually reflect worsening airway inflammation. Repeated SABA use alone treats bronchospasm but does little for the underlying inflammatory process.
Why the move away from SABA-heavy treatment?
Traditional asthma management has often unintentionally reinforced overreliance on salbutamol. Children feel better quickly after using it, so they naturally reach for it repeatedly, while adherence to preventer inhalers is often poor.
To quantify this risk in the UK, the landmark National Review of Asthma Deaths (NRAD) highlighted a link between patients who died from asthma and excessive use of SABA. Specifically, 39% of those using SABA at the time of death had been prescribed more than 12 reliever inhalers in the previous year, while most were undertreated with inhaled corticosteroids (Royal College of Physicians, 2014).
This is mirrored internationally by the SABINA programme, a large series of real-world asthma studies demonstrating a clear dose-dependent association between increasing SABA prescriptions and worsening asthma outcomes. Collectively, this robust body of evidence has driven a paradigm shift toward ICS–formoterol-based pathways such as AIR and MART (Nwaru et al., 2020).
As established across these data, frequent SABA use without adequate anti-inflammatory coverage is heavily associated with:
- Increased exacerbations
- Higher hospital admission rates
- Poorer overall asthma control
- Increased asthma mortality
ICS–formoterol strategies directly target this behavioural and physiological loop by linking symptom relief safely with an immediate dose of anti-inflammatory treatment.
Studies in adults and adolescents, such as the SYGMA programme (O’Byrne et al., 2018; Bateman et al., 2018), and the Novel START trial (Beasley et al., 2019), have demonstrated reduced severe exacerbations with ICS–formoterol strategies compared with traditional SABA-based regimens, although evidence in younger children remains more limited.
AIR and MART: the new pathway in over-12s
A key change in the updated guidance is that ICS–formoterol now sits at the centre of asthma management in most people aged 12 years and over.
AIR therapy
For patients with milder asthma, the preferred starting pathway is often AIR (Anti-inflammatory Reliever) therapy (NICE, 2024).
With AIR:
– the patient uses an ICS/formoterol inhaler only when symptomatic
– there is no separate salbutamol reliever
– every “reliever” dose also delivers inhaled steroid
MART therapy
For patients with more frequent symptoms, higher risk features, or recent exacerbations, the pathway moves towards MART (NICE, 2024).
With MART:
– the same ICS/formoterol inhaler is used for both maintenance and symptom relief
– patients take regular daily doses plus additional doses when symptomatic
If control improves, some patients may later step down from MART to AIR therapy following specialist review.
Traditional SABA-based pathways still exist, but they are no longer the preferred starting approach for most adolescents if ICS/formoterol is suitable and tolerated.
MART in children aged 5–11 years
This is where things become more nuanced.
In younger children, the issue is often not the principle of MART — it is the device.
Many MART inhalers are dry powder inhalers (DPIs), such as:
- Symbicort Turbohaler
- Fobumix
Unlike metered-dose inhalers (MDIs), DPIs rely entirely on the patient generating sufficient inspiratory flow to deliver the drug effectively.
This creates a practical divide in the 5–11 age group.
Children able to use a DPI effectively
If the child can generate sufficient inspiratory flow and demonstrate good technique, low-dose MART may be considered in selected patients whose asthma remains uncontrolled on paediatric low-dose ICS plus SABA therapy.
This can be particularly useful in children with:
– recurrent exacerbations
– poor adherence to separate preventers
– frequent “mini-flares”
Children unable to use a DPI effectively
Some children remain better suited to traditional MDI plus spacer-based regimens.
If effective DPI use is not possible, escalation may continue through more traditional pathways such as:
– additional LABA therapy
– leukotriene receptor antagonists (LTRAs)
– higher-dose ICS strategies
This partly explains why implementation of MART in primary school-aged children is often more selective and specialist-led than in adolescents.
Under 5s: standard pathways still apply
MART is not routinely recommended in preschool children (NICE, 2024).
At this age:
- diagnosing asthma remains challenging
- many children have episodic viral wheeze rather than persistent asthma
- and most preschool children are unable to reliably use dry powder inhalers
Management continues to focus on:
- symptom pattern recognition
- trial of low-dose ICS where appropriate
- trigger reduction
- and regular reassessment of diagnosis and response
Which inhalers can be used for MART?
The key ingredient is formoterol, because it has a rapid onset of action (GINA, 2025).
Common UK MART inhalers include:
Symbicort (budesonide/formoterol)
Fobumix
The “Dry Powder” Problem
Almost all inhalers licensed for MART are Dry Powder Inhalers (DPIs). Unlike the “puffer” (MDI) and spacer we use in the ED, a DPI has no propellant. The drug only moves if the patient moves it.
- The “Suck” Test: To get the powder into the lungs, the child must be able to take a sharp, deep, forceful breath.
- Practical Difficulty: Many children under 10 simply cannot generate the required inspiratory flow, especially when they feel tight-chested. If they can’t “suck” hard enough, the medicine stays in the device rather than in the airways.
The Licensing Maze
As of late 2025, the licensing for MART in children is very specific; see figure 1, (NICE, 2024):
- Ages 12+: Most ICS/Formoterol brands are licensed.
- Ages 6–11: Only one specific budesonide/formoterol DPI (100 micrograms/6 micrograms) is currently licensed for MART.
- Off-label use: Any other MART brand used in a child under 12 is technically “off-label,” which is why you’ll see such a strong preference for specific devices in your local guidelines.
In the emergency department, parents may recognise these inhalers by brand name, colour, or device rather than by drug class, so it is worth becoming familiar with common MART inhalers used locally.
Figure 1: Figure 1. Common ICS/formoterol inhalers used for AIR and MART therapy in children and young people, adapted from NICE NG245 (2024). This is not an exhaustive list and local formularies should always be consulted.
Practical considerations in the Emergency Department
MART does not replace acute asthma management
Children presenting with acute severe asthma still require standard evidence-based escalation including (NICE, 2024):
salbutamol
ipratropium bromide
systemic corticosteroids
oxygen where required
intravenous therapies where indicated
A child already using MART can still become critically unwell. What differs is how they are treated at home and their individual thresholds for admission. Figure 2 outlines the differences between emergency management of an asthma exacerbation at home on conventional SABA/ICS therapy compared to MART regime. Do not underestimate severity because they have already used their combination inhaler at home.
Medication histories can sound unusual
Parents may report:
“He takes the same inhaler every morning and whenever he’s wheezy.”
This may represent entirely appropriate MART use rather than reliever overuse.
Discharge conversations still matter
Children and families still require:
- personalised asthma action plans
- clear maximum daily inhaler doses
- education around worsening symptoms
- and safety-netting advice regarding when to seek urgent review
Implementation of AIR and MART pathways is also likely to vary regionally as local pathways evolve.
Figure 2: Simplified home management pathways for acute asthma in children and young people receiving conventional or AIR/MART therapy, adapted from NICE NG245 (2024).
ICS–formoterol links symptom relief directly with anti-inflammatory treatment
Check inhaler technique before considering MART—effective DPI use is essential.
Licensing and local formularies matter, particularly in the 5–11-year age group.
Every child receiving AIR or MART should have an up-to-date personalised asthma action plan (PAAP).
References
National Institute for Health and Care Excellence (2024) Asthma: diagnosis, monitoring and chronic asthma management (NG245). London: NICE. Available at: https://www.nice.org.uk/guidance/ng245 (Accessed: 30th June 2026).
British Thoracic Society, National Institute for Health and Care Excellence and Scottish Intercollegiate Guidelines Network (2024) Asthma guideline algorithms. Available at: https://www.nice.org.uk/guidance/ng245/resources (Accessed: 30th June 2026).
Global Initiative for Asthma (2025) Global Strategy for Asthma Management and Prevention. Fontana, WI: GINA. Available at: https://ginasthma.org (30th June 2026).
O’Byrne, P.M., FitzGerald, J.M., Bateman, E.D. et al. (2018) ‘Inhaled combined budesonide–formoterol as needed in mild asthma’, New England Journal of Medicine, 378, pp. 1865–1876.
Beasley, R., Holliday, M., Reddel, H.K. et al. (2019) ‘Controlled trial of budesonide–formoterol as needed for mild asthma’, New England Journal of Medicine, 380, pp. 2020–2030.
Nwaru, B.I., Ekström, M., Hasvold, P. et al. (2020) ‘Overuse of short-acting β2-agonists in asthma is associated with increased risk of exacerbation and mortality: a nationwide cohort study’, European Respiratory Journal, 55(4), 1901872.
Janson, C., Menzies-Gow, A., Nan, C. et al. (2020) ‘SABINA: an overview of short-acting β2-agonist use in asthma in European countries’, Advances in Therapy, 37, pp. 1124–1135.
