GINA Asthma

8/10/2019 GINA Asthma

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BASED ON THE GLOBAL STRATEGY FOR ASTHMAMANAGEMENT AND PREVENTION

Global Initiative for Asthma


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Board of Directors (2011)

Eric D. Bateman, M.D., South Africa, Chair

Louis-Philippe Boulet, M.D., CanadaAlvaro Cruz, M.D., Brazil

Mark FitzGerald, M.D., Canada

Tari Haahtela, M.D., Finland

Mark Levy, M.D., United Kingdom

Paul OByrne, M.D., Canada

Ken Ohta, M.D., Japan

Pierluigi Paggario, M.D., ItalySoren Pedersen, M.D., Denmark

Manuel Soto-Quiroz, M.D., Costa Rica

Gary Wong, M.D., Hong Kong ROC

GINA Assembly (2011)

Louis-Philippe Boulet, MD, Canada, Chair

GINA Assembly members from 45countries (names are listed on website:www.ginasthma.org)

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Global Initiative for Asthma


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TABLE OF CONTENTSPREFACE 3

WHAT IS KNOWN ABOUT ASTHMA? 5DIAGNOSING ASTHMA 7

Figure 1. Is it Asthma? 7

CLASSIFICATION OF ASTHMA BY LEVEL OF CONTROL 9

Figure 2. Levels of Asthma Control 9

FOUR COMPONENTS OF ASTHMA CARE 10

Component 1. Develop Patient/Doctor Partnership 10

Figure 3. Example of Contents of an Action Plan to MaintainAsthma Control 11

Component 2. Identify and Reduce Exposure to Risk Factors 12

Figure 4. Strategies for Avoiding Common Allergens and Pollutants 12

Component 3. Assess, Treat, and Monitor Asthma 13

Figure 5. Management Approach Based on Control 15

Figure 6. Estimated Equipotent Doses of Inhaled Glucocorticosteroids 16

Figure 7. Questions for Monitoring Asthma care 18

Component 4. Manage Exacerbations 19

Figure 8. Severity of Asthma Exacerbations 22

SPECIAL CONSIDERATIONS IN MANAGING ASTHMA 23

Appendix A: Glossary of Asthma Medications - Controllers 24

Appendix B: Combination Medications for Asthma 25

Appendix C: Glossary of Asthma Medications - Relievers 26


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PREFACE

Asthma is a major cause of chronic morbidity and mortality throughout theworld and there is evidence that its prevalence has increased considerablyover the past 20 years, especially in children. The Global Initiative for

Asthma was created to increase awareness of asthma among healthprofessionals, public health authorities, and the general public, and toimprove prevention and management through a concerted worldwideeffort. The Initiative prepares scientific reports on asthma, encourages

dissemination and implementation of the recommendations, and promotesinternational collaboration on asthma research.

The Global Initiative for Asthmaoffers a framework to achieve and maintainasthma control for most patients that can be adapted to local health caresystems and resources. Educational tools, such as laminated cards, orcomputer-based learning programs can be prepared that are tailored tothese systems and resources.

The Global Initiative for Asthmaprogram publications include:

Global Strategy for Asthma Management and Prevention(2011).Scientific information and recommendations for asthma programs.

Global Strategy for Asthma Management and PreventionGINA Executive Summary. Eur Respir J 2008; 31: 1-36

Pocket Guide for Asthma Management and Prevention for Adultsand Children Older Than 5 Years(2011). Summary of patient care

information for primary health care professionals. Pocket Guide for Asthma Management and Prevention in Children 5

Years and Younger(2009). Summary of patient care information forpediatricians and other health care professionals.

What You and Your Family Can Do About Asthma.An informationbooklet for patients and their families.

Publications are available from www.ginasthma.org.

This Pocket Guide has been developed from the Global Strategy for AsthmaManagement and Prevention (Updated 2011). Technical discussions ofasthma, evidence levels, and specific citations from the scientific literatureare included in that source document.


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Acknowledgements:

Grateful acknowledgement is given for unrestricted educational grants

from Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi Group, CIPLA,GlaxoSmithKline, Merck Sharp & Dohme, Novartis, Nycomed andPharmaxis. The generous contributions of these companies assured that theGINA Committees could meet together and publications could be printedfor wide distribution. However, the GINA Committee participants are solelyresponsible for the statements and conclusions in the publications.


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WHAT IS KNOWN

ABOUT ASTHMA?Unfortunatelyasthma is one of the most common chronic diseases, withan estimated 300 million individuals affected worldwide. Its prevalence isincreasing, especially among children.

Fortunatelyasthma can be effectively treated and most patients canachieve good control of their disease. When asthma is under controlpatients can:

Avoid troublesome symptoms night and day Use little or no reliever medication Have productive, physically active lives Have (near) normal lung function Avoid serious attacks

Asthma causes recurring episodes of wheezing, breathlessness, chesttightness, and coughing, particularly at night or in the early morning.

Asthma is a chronic inflammatory disorderof the airways. Chronicallyinflamed airways are hyperresponsive; they become obstructed andairflow is limited (by bronchoconstriction, mucus plugs, and increasedinflammation) when airways are exposed to various risk factors.

Common risk factorsfor asthma symptoms include exposure to allergens(such as those from house dust mites, animals with fur, cockroaches,

pollens, and molds), occupational irritants, tobacco smoke, respiratory(viral) infections, exercise, strong emotional expressions, chemicalirritants, and drugs (such as aspirin and beta blockers).

A stepwise approach to pharmacologic treatment to achieve andmaintain control of asthma should take into account the safety oftreatment, potential for adverse effects, and the cost of treatmentrequired to achieve control.

Asthma attacks(or exacerbations) are episodic, but airway inflammationis chronically present.


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For many patients, controller medication must be taken daily to preventsymptoms, improve lung function, and prevent attacks. Relievermedications may occasionally be required to treat acute symptoms such

as wheezing, chest tightness, and cough.

To reach and maintain asthma control requires the development of apartnershipbetween the person with asthma and his or her health careteam.

Asthma is not a cause for shame. Olympic athletes, famous leaders,other celebrities, and ordinary people live successful liveswith asthma.


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DIAGNOSING ASTHMA

Asthma can often be diagnosed on the basis of a patients symptomsandmedical history(Figure 1).

Measurements of lung function provide an assessment of the severity,repairability, and variability of airflow limitation, and help confirm thediagnosis of asthma.

Spirometryis the preferred method of measuring airflow limitation and itsreversibility to establish a diagnosis of asthma.

An increase in FEV1of 12% and 200 ml after administration

of a bronchodilator indicates reversible airflow limitation consistentwith asthma. (However, most asthma patients will not exhibit reversibilityat each assessment, and repeated testing is advised.)

Presence of any of these signs and symptoms should increase the suspicion of asthma:

Wheezing high-pitched whistling sounds when breathing outespecially in children. (A normal chest examination does not exclude asthma.)

History of any of the following: Cough, worse particularly at night Recurrent wheeze Recurrent difficult breathing Recurrent chest tightness

Symptoms occur or worsen at night, awakening the patient. Symptoms occur or worsen in a seasonal pattern.

The patient also has eczema, hay fever, or a family history of asthma or atopic diseases.

Symptoms occur or worsen in the presence of: Animals with fur Aerosol chemicals Changes in temperature Domestic dust mites Drugs (aspirin, beta blockers) Exercise Pollen Respiratory (viral) infections Smoke Strong emotional expression

Symptoms respond to ant-asthma therapy Patients colds "go to the chest" or take more than 10 days to clear up

Figure 1. Is it Asthma?


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Peak expiratory flow (PEF)measurements can be an important aid in bothdiagnosis and monitoring of asthma. PEF measurements are ideally compared to the patients own previous

best measurements using his/her own peak flow meter. An improvement of 60 L/min (or20% of the pre-bronchodilator PEF)

after inhalation of a bronchodilator, or diurnal variation in PEF ofmore than 20% (with twice-daily readings, more than 10%), suggestsa diagnosis of asthma.

Additional diagnostic tests:

For patients with symptoms consistent with asthma, but normal lungfunction, measurements of airway responsiveness to methacholineand histamine, an indirect challenge test such as inhaled mannitol, or

exercise challenge may help establish a diagnosis of asthma. Skin tests with allergens or measurement of specific IgE in serum:

The presence of allergies increases the probability of a diagnosisof asthma, and can help to identify risk factors that cause asthmasymptoms in individual patients.

Diagnostic Challenges

Cough-variant asthma.Some patients with asthma have chronic cough(frequently occurring at night) as their principal, if not only, symptom.

For these patients, documentation of lung function variability andairway hyperresponsiveness are particularly important.

Exercise-induced bronchoconstriction.Physical activity is an importantcause of asthma symptoms for most asthma patients, and for some(including many children) it is the only cause. Exercise testing with an8-minute running protocol can establish a firm diagnosis of asthma.

Children 5 Years and Younger. Not all young children who wheezehave asthma. In this age group, the diagnosis of asthma must be basedlargely on clinical judgment, and should be periodically reviewed as

the child grows (see the GINA Pocket Guide for Asthma Managementand Prevention in Children 5 Years and Youngerfor further details).

Asthma in the elderly.Diagnosis and treatment of asthma in the elderlyare complicated by several factors, including poor perception ofsymptoms, acceptance of dyspnea as being normal for old age, andreduced expectations of mobility and activity. Distinguishing asthmafrom COPD is particularly difficult, and may require a trial of treatment.

Occupational asthma. Asthma acquired in the workplace is adiagnosis that is frequently missed. The diagnosis requires a defined

history of occupational exposure to sensitizing agents; an absence ofasthma symptoms before beginning employment; and a documentedrelationship between symptoms and the workplace (improvement insymptoms away from work and worsening of symptoms upon returningto work).


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CLASSIFICATION OF ASTHMA

BY LEVEL OF CONTROLThe goal of asthma care is to achieve and maintain control of the clinicalmanifestations of the disease for prolonged periods. When asthma iscontrolled, patients can prevent most attacks, avoid troublesome symptomsday and night, and keep physically active.

The assessment of asthma control should include control of the clinicalmanifestations and control of the expected future risk to the patient suchas exacerbations, accelerated decline in lung function, and side-effects of

treatment. In general, the achievement of good clinical control of asthmaleads to reduced risk of exacerbations.

Figure 2describes the clinical characteristics of controlled, partly controlled,and uncontrolled asthma.

Examples of validated measures for assessing clinical control of asthma include: Asthma Control Test (ACT): www.asthmacontrol.com

Childhood Asthma Control test (C-Act)

Asthma Control Questionnaire (ACQ): www.qoltech.co.uk/Asthma1.htm

Asthma Therapy Assessment Questionnaire (ATAQ): www.ataqinstrument.com

Asthma Control Scoring System

Figure 2. Levels of Asthma Control

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FOUR COMPONENTS OF

ASTHMA CAREFour interrelated components of therapy are required to achieve and maintaincontrol of asthma:

Component 1.Develop patient/doctor partnershipComponent 2.Identify and reduce exposure to risk factorsComponent 3.Assess, treat, and monitor asthmaComponent 4. Manage asthma exacerbations

Component 1: Develop Patient/Doctor Partnership

The effective management of asthma requires the development of a partnershipbetween the person with asthma and his or her health care team.

With your help, and the help of others on the health care team, patients canlearn to:

Avoid risk factors Take medications correctly Understand the difference between "controller" and "reliever" medications Monitor their status using symptoms and, if relevant, PEF Recognize signs that asthma is worsening and take action Seek medical advice as appropriate

Education should be an integral part of all interactions between health careprofessionals and patients. Using a variety of methodssuch as discussions

(with a physician, nurse, outreach worker, counselor, or educator),demonstrations, written materials, group classes, video or audio tapes,dramas, and patient support groupshelps reinforce educational messages.

Working together, you and your patient should prepare a written personalasthma action plan that is medically appropriate and practical. A sampleasthma plan is shown in Figure 3.

Additional written asthma action plans can be found on several websites,

including:www.asthma.org.ukwww.nhlbisupport.com/asthma/index.htmlwww.asthmanz.co.nz


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Component 2: Identify and Reduce Exposure to Risk Factors

To improve control of asthma and reduce medication needs, patients shouldtake steps to avoid the risk factors that cause their asthma symptoms (Figure

4). However, many asthma patients react to multiple factors that are ubiquitousin the environment, and avoiding some of these factors completely is nearlyimpossible. Thus, medications to maintain asthma control have an importantrole because patients are often less sensitive to these risk factors when theirasthma is under control.

Physical activity is a common cause of asthma symptoms but patients should notavoid exercise.Symptoms can be prevented by taking a rapid-acting inhaled

2-agonist before strenuous exercise (a leukotriene modifier or cromone are

alternatives).

Patients with moderate to severe asthma should be advised to receive aninfluenza vaccinationevery year, or at least when vaccination of the generalpopulation is advised. Inactivated influenza vaccines are safe for adults andchildren over age 3.

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Component 3: Assess, Treat and Monitor Asthma

The goal of asthma treatmentto achieve and maintain clinical control

can be reached in most patients through a continuous cycle that involves Assessing Asthma Control Treating to Achieve Control Monitoring to Maintain Control

Assessing Asthma Control

Each patient should be assessed to establish his or her current treatment

regimen, adherence to the current regimen, and level of asthma control.A simplified scheme for recognizing controlled, partly controlled, anduncontrolled asthma is provided in Figure 2.

Treating to Achieve Control

Each patient is assigned to one of five treatment steps. Figure 5details thetreatments at each step for adults and children age 5 and over.

At each treatment step, reliever medication should be provided for quickrelief of symptoms as needed. (However, be aware of how much relievermedication the patient is usingregular or increased use indicates thatasthma is not well controlled.)

At Steps 2 through 5, patients also require one or more regular controllermedications, which keep symptoms and attacks from starting. Inhaledglucocorticosteroids (Figure 6) are the most effective controller medications

currently available.

For most patients newly diagnosed with asthma or not yet on medication,treatment should be started at Step 2 (or if the patient is very symptomatic,at Step 3). If asthma is not controlled on the current treatment regimen,treatment should be stepped up until control is achieved.

Patients who do not reach an acceptable level of control at Step 4 can beconsidered to have difficult-to-treat asthma. In these patients, a compromisemay need to be reached focusing on achieving the best level of controlfeasiblewith as little disruption of activities and as few daily symptoms aspossiblewhile minimizing the potential for adverse effects from treatment.Referral to an asthma specialist may be helpful.


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A variety of controller (Appendix AandAppendix B) and reliever (AppendixC) medications for asthma are available. The recommended treatments areguidelines only. Local resources and individual patient circumstances should

determine the specific therapy prescribed for each patient.Inhaled medicationsare preferred because they deliver drugs directly to theairways where they are needed, resulting in potent therapeutic effects withfewer systemic side effects. Inhaled medications for asthma are availableas pressurized metered-dose inhalers (pMDIs), breath-actuated MDIs, drypowder inhalers (DPIs), and nebulizers. Spacer (or valved holding-chamber)devices make inhalers easier to use and reduce systemic absorption andside effects of inhaled glucocorticosteroids.

Teach patients (and parents) how to use inhaler devices. Different devicesneed different inhalation techniques.

Give demonstrations and illustrated instructions. Ask patients to show their technique at every visit. Information about use of various inhaler devices is found on the

GINA Website (www.ginasthma.org).


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Mild attacks, defined by a reduction in peak flow of less than 20%, nocturnalawakening, and increased us of rapid-acting

2-agonists, can usually be treated

at home if the patient is prepared and has a personal asthma managementplan that includes action steps.

Moderate attacks may require, and severe attacks usually require, care in aclinic or hospital.

Asthma attacks require prompt treatment:

Inhaled rapid-acting 2-agonists in adequate does are essential.

(Begin with 2 to 4 puffs every 20 minutes for the first hour; then mildexacerbations will require 2 to 4 puffs every 3 to 4 hours, and moderateexacerbations 6 to 10 puffs every 1 to 2 hours.)

Oral glucocorticosteroids (0.5 to 1 mg of prednisolone/kg or equivalentduring a 24-hour period) introduced early in the course of a moderate orsevere attack help to reverse the inflammation and speed recovery.

Oxygen is given at health centers or hospitals if the patient is hyopxemic(achieve O

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Combination 2-agonists/anticholinergic therapy is associated with

lower hospitalization rates and greater improvement in PEF and FEV1.

Methylxanthines are not recommended if used in addition to highdoses of inhaled 2-agonists. However, theophylline can be used ifinhaled

2-agonists are not available. If the patient is already taking

theophylline on a daily basis, serum concentration should be measuredbefore adding short-acting theophylline.

Patients with severe asthma exacerbations unresponsive to bronchodilatorsand systemic glucocorticosteroids, 2 grams of magnesium sulphate IV hasbeen shown to reduce the need to hospitalizations.

Therapies not recommended for treating asthma attacks include:

Sedatives (strictly avoid) Mucolytic drugs (may worsen cough) Chest physical therapy/physiotherapy (may increase patient discomfort) Hydration with large volumes of fluid for adults and older children (may be

necessary for younger children and infants) Antibiotics (do not treat attacks but are indicated for patients who also

have pneumonia or bacterial infection such as sinusitis) Epinephrine/adrenaline (may be indicated for acute treatment of

anaphylaxis and angioedema but is not indicated for asthma attacks)


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Monitor response to treatment:

Evaluate symptoms and, as much as possible, peak flow. In the hospital, alsoassess oxygen saturation; consider arterial blood gas measurement in patientswith suspected hypoventilation, exhaustion, severe distress, or peak flow 30-50percent predicted.

Follow up:

After the exacerbation is resolved, the factors that precipitated the exacerbationshould be identified and strategies for their future avoidance implemented, andthe patients medication plan reviewed.


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SPECIAL CONSIDERATIONS

IN MANAGING ASTHMA PregnancyDuring pregnancy the severity of asthma often changes, and patientsmay require close follow-up and adjustment of medications. Pregnant patientswith asthma should be advised that the greater risk to their baby lies with poorlycontrolled asthma, and the safety of most modern asthma treatments should bestressed. Acute exacerbations should be treated aggressively to avoid fetal hypoxia.

Obesity. Management of asthma in the obese should be the same as patients withnormal weight. Weight loss in the obese patient improves asthma control, lung

function and reduces medication needs. Surgery.Airway hyperresponsiveness, airflow limitation, and mucus hyper-secretion

predispose patients with asthma to intraoperative and postoperative respiratorycomplications, particularly with thoracic and upper abdominal surgeries. Lungfunction should be evaluated several days prior to surgery, and a brief course ofglucocorticosteroids prescribed if FEV

1is less than 80% of the patients personal

best.

Rhinitis, Sinusitis, and Nasal Polyps.Rhinitis and asthma often coexist in the samepatient, and treatment of rhinitis may improve asthma symptoms. Both acute and

chronic sinusitis can worsen asthma, and should be treated. Nasal polyps areassociated with asthma and rhinitis, often with aspirin sensitivity and most frequentlyin adult patients. They are normally quite responsive to topical glucocorticosteroids.

Occupational asthma.Pharmacologic therapy for occupational asthma is identicalto therapy for other forms of asthma, but is not a substitute for adequate avoidanceof the relevant exposure. Consultation with a specialist in asthma management oroccupational medicine is advisable.

Respiratory infections. Respiratory infections provoke wheezing and increasedasthma symptoms in many patients. Treatment of an infectious exacerbation followsthe same principles as treatment of other exacerbations.

Gastroesophageal reflux.Gastroesophageal reflux is more common in patientswith asthma compared to the general population. However, treatment with protonpump inhibitors, H

2antagonists or surgery fail to improve asthma control.

Aspirin-induced asthma. Up to 28 percent of adults with asthma, but rarelychildren, suffer from asthma exacerbations in response to aspirin and othernonsteroidal anti-inflammatory drugs. The diagnosis can only be confirmed byaspirin challenge, which must be conducted in a facility with cardiopulmonary

resuscitation capabilities. Complete avoidance of the drugs that cause symptoms isthe standard management.

Anaphylaxis.Anaphylaxis is a potentially life-threatening condition that can bothmimic and complicate severe asthma. Prompt treatment is crucial and includesoxygen, intramuscular epinephrine, injectable antihistamine, intravenoushydrocortisone, and intravenous fluid.


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NOTES


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NOTES


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The Global Initiative for Asthma is supported by unrestricted education grants from:

h b h

AlmirallAstraZeneca

Boehringer Ingelheim

Chiesi Group

CIPLAGlaxoSmithKline

Merck Sharp & Dohme

Novartis

NycomedPharmaxis

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GINA Asthma