GINA Slide Set 2006

G INA

G INA

lobal

itiative for

sthma

lobal

itiative for

sthma

Definition of AsthmaDefinition of Asthma

A chronic inflammatory disorder of the airways

Many cells and cellular elements play a role

Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing

Widespread, variable, and often reversible airflow limitation

A chronic inflammatory disorder of the airways

Many cells and cellular elements play a role

Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing

Widespread, variable, and often reversible airflow limitation

Source: Peter J. Barnes, MDSource: Peter J. Barnes, MD

Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, Source: Peter J. Barnes, MDMD

Mechanisms: Asthma Inflammation

Source: Peter J. Barnes, Source: Peter J. Barnes, MDMD

Asthma Inflammation: Cells and Mediators

Burden of Asthma

Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals

Prevalence increasing in many countries, especially in children

A major cause of school/work absence

Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals

Prevalence increasing in many countries, especially in children

A major cause of school/work absence

Burden of Asthma

Health care expenditures very high

Developed economies might expect to spend 1-2 percent of total health care expenditures on asthma. Developing economies likely to face increased demand

Poorly controlled asthma is expensive; investment in prevention medication likely to yield cost savings in emergency care

Health care expenditures very high

Developed economies might expect to spend 1-2 percent of total health care expenditures on asthma. Developing economies likely to face increased demand

Poorly controlled asthma is expensive; investment in prevention medication likely to yield cost savings in emergency care

Asthma Prevalence and Mortality

SourceSource: Masoli M et al. Allergy 2004: Masoli M et al. Allergy 2004

Countries should enter their own data on burden of asthma.

Countries should enter their own data on burden of asthma.

Risk Factors for Asthma

Host factors: predispose individuals to, or protect them from, developing asthma

Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist

Host factors: predispose individuals to, or protect them from, developing asthma

Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist

Factors that Exacerbate AsthmaFactors that Exacerbate Asthma

Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs

Factors that Influence Asthma Development and Expression

Host Factors Genetic - Atopy - Airway

hyperresponsiveness Gender Obesity

Host Factors Genetic - Atopy - Airway

hyperresponsiveness Gender Obesity

Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Diet

Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Diet

Is it Asthma?Is it Asthma?

Recurrent episodes of wheezing Troublesome cough at night Cough or wheeze after exercise Cough, wheeze or chest tightness after

exposure to airborne allergens or pollutants

Colds “go to the chest” or take more than 10 days to clear

Asthma Diagnosis

History and patterns of symptoms

Measurements of lung function

- Spirometry - Peak expiratory flow

Measurement of airway responsiveness

Measurements of allergic status to identify risk factors

Extra measures may be required to diagnose asthma in children 5 years and younger and the elderly

History and patterns of symptoms

Measurements of lung function

- Spirometry - Peak expiratory flow

Measurement of airway responsiveness

Measurements of allergic status to identify risk factors

Extra measures may be required to diagnose asthma in children 5 years and younger and the elderly

Typical Spirometric (FEV1) TracingsTypical Spirometric (FEV1) Tracings

11Time (sec)Time (sec)22 33 44 55

FEV1FEV1

VolumeVolume

Normal SubjectNormal Subject

Asthmatic (After Bronchodilator)Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)Asthmatic (Before Bronchodilator)

Note: Each FEV1 curve represents the highest of three repeat measurements

Measuring Variability of Peak Expiratory Flow

Measuring Airway Responsiveness

Clinical Control of Asthma

No (or minimal)* daytime symptoms

No limitations of activity

No nocturnal symptoms

No (or minimal) need for rescue medication

Normal lung function

No exacerbations_________* Minimal = twice or less per week

Levels of Asthma Control

CharacteristicControlled

(All of the following)Partly controlled

(Any present in any week)Uncontrolled

Daytime symptomsNone (2 or less / week)

More than twice / week

3 or more features of partly controlled asthma present in any week

Limitations of activities

None Any

Nocturnal symptoms / awakening

None Any

Need for rescue / “reliever” treatment

None (2 or less / week)


Lung function (PEF or FEV1)

Normal< 80% predicted or

personal best (if known) on any day

Exacerbation None One or more / year 1 in any week

1. Develop Patient/Doctor Partnership

2. Identify and Reduce Exposure to Risk Factors

3. Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations

5. Special Considerations






Asthma Management and PreventionProgram: Five ComponentsAsthma Management and PreventionProgram: Five Components

Revised 2006

Asthma Management and Prevention Program: Five Interrelated Components











Asthma Management and Prevention Program

Goals of Long-term Management

Achieve and maintain control of symptoms

Maintain normal activity levels, including exercise

Maintain pulmonary function as close to normal levels as possible

Prevent asthma exacerbations Avoid adverse effects from asthma

medications Prevent asthma mortality

Achieve and maintain control of symptoms

Maintain normal activity levels, including exercise

Maintain pulmonary function as close to normal levels as possible

Prevent asthma exacerbations Avoid adverse effects from asthma

medications Prevent asthma mortality


Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms

Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.


Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.

.


Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control

Guidelines on asthma management should be available but adapted and adopted for local use by local asthma planning teams

Clear communication between health care professionals and asthma patients is key to enhancing compliance

Guidelines on asthma management should be available but adapted and adopted for local use by local asthma planning teams

Clear communication between health care professionals and asthma patients is key to enhancing compliance


Component 1: Develop Patient/Doctor Partnership







Educate continually

Include the family

Provide information about asthma

Provide training on self-management skills

Emphasize a partnership among health care providers, the patient, and the patient’s family

Educate continually

Include the family

Provide information about asthma

Provide training on self-management skills

Emphasize a partnership among health care providers, the patient, and the patient’s family





Key factors to facilitate communication:

Friendly demeanor

Interactive dialogue

Encouragement and praise

Provide appropriate information

Feedback and review

Key factors to facilitate communication:

Friendly demeanor

Interactive dialogue

Encouragement and praise

Provide appropriate information

Feedback and review

Example Of Contents Of An Action Plan To Maintain Asthma Control

Your Regular Treatment: 1. Each day take ___________________________ 2. Before exercise, take _____________________

WHEN TO INCREASE TREATMENTAssess your level of Asthma ControlIn the past week have you had: Daytime asthma symptoms more than 2 times ? No Yes Activity or exercise limited by asthma? No Yes Waking at night because of asthma? No Yes The need to use your [rescue medication] more than 2 times? No Yes If you are monitoring peak flow, peak flow less than________? No YesIf you answered YES to three or more of these questions, your asthma is uncontrolled and you may need to step up your treatment.

HOW TO INCREASE TREATMENTSTEP-UP your treatment as follows and assess improvement every day:____________________________________________ [Write in next treatment step here] Maintain this treatment for _____________ days [specify number]

WHEN TO CALL THE DOCTOR/CLINIC.Call your doctor/clinic: _______________ [provide phone numbers]If you don’t respond in _________ days [specify number]______________________________ [optional lines for additional instruction]

EMERGENCY/SEVERE LOSS OF CONTROLIf you have severe shortness of breath, and can only speak in short sentences,If you are having a severe attack of asthma and are frightened,If you need your reliever medication more than every 4 hours and are not improving.1. Take 2 to 4 puffs ___________ [reliever medication] 2. Take ____mg of ____________ [oral glucocorticosteroid]3. Seek medical help: Go to _____________________; Address___________________ Phone: _______________________4. Continue to use your _________[reliever medication] until you are able to get medical help.


Factors Involved in Non-AdherenceAsthma Management and Prevention Program

Factors Involved in Non-Adherence

Medication Usage Difficulties associated

with inhalers

Complicated regimens

Fears about, or actual side effects

Cost

Distance to pharmacies

Medication Usage Difficulties associated

with inhalers

Complicated regimens

Fears about, or actual side effects

Cost

Distance to pharmacies

Non-Medication Factors

Misunderstanding/lack of information

Fears about side-effects

Inappropriate expectations

Underestimation of severity

Attitudes toward ill health

Cultural factors

Poor communication

Non-Medication Factors

Misunderstanding/lack of information

Fears about side-effects

Inappropriate expectations

Underestimation of severity

Attitudes toward ill health

Cultural factors

Poor communication


Component 2: Identify and Reduce Exposure to Risk Factors



Measures to prevent the development of asthma, and asthma exacerbations by avoiding or reducing exposure to risk factors should be implemented wherever possible.

Asthma exacerbations may be caused by a variety of risk factors – allergens, viral infections, pollutants and drugs.

Reducing exposure to some categories of risk factors improves the control of asthma and reduces medications needs.

Reduce exposure to indoor allergens Avoid tobacco smoke Avoid vehicle emission Identify irritants in the workplace Explore role of infections on asthma

development, especially in children and young infants






Influenza VaccinationAsthma Management and Prevention Program

Influenza Vaccination

Influenza vaccination should be provided to patients with asthma when vaccination of the general population is advised

However, routine influenza vaccination of children and adults with asthma does not appear to protect them from asthma exacerbations or improve asthma control


Component 3: Assess, Treat and Monitor Asthma



The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional

The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional





Depending on level of asthma control, the patient is assigned to one of five treatment steps

Treatment is adjusted in a continuous cycle driven by changes in asthma control status. The cycle involves:

- Assessing Asthma Control

- Treating to Achieve Control

- Monitoring to Maintain Control

A stepwise approach to pharmacological therapy is recommended

The aim is to accomplish the goals of therapy with the least possible medication

Although in many countries traditional methods of healing are used, their efficacy has not yet been established and their use can therefore not be recommended

A stepwise approach to pharmacological therapy is recommended

The aim is to accomplish the goals of therapy with the least possible medication

Although in many countries traditional methods of healing are used, their efficacy has not yet been established and their use can therefore not be recommended





The choice of treatment should be guided by: Level of asthma control Current treatment Pharmacological properties and availability

of the various forms of asthma treatment Economic considerations

Cultural preferences and differing health caresystems need to be considered









Characteristic Controlled Partly controlled(Any present in any week)

Uncontrolled

Daytime symptomsNone (2 or less / week)


3 or more features of partly controlled asthma present in any week


None Any

Nocturnal symptoms / awakening

None Any

Need for rescue / “reliever” treatment

None (2 or less / week)



Normal< 80% predicted or

personal best (if known) on any day

Exacerbation None One or more / year 1 in any week











Component 4: Asthma Management and Prevention Program

Controller MedicationsComponent 4: Asthma Management and Prevention Program

Controller Medications

Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists Systemic glucocorticosteroids Theophylline Cromones Long-acting oral β2-agonists Anti-IgE Systemic glucocorticosteroids

Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists Systemic glucocorticosteroids Theophylline Cromones Long-acting oral β2-agonists Anti-IgE Systemic glucocorticosteroids

Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by AgeEstimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age

Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)

> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)

> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y

Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400

Budesonide 200-600 100-200

600-1000 >200-400 >1000 >400

Budesonide-Neb Inhalation Suspension

250-500

>500-1000

>1000

Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320

Flunisolide 500-1000 500-750

>1000-2000 >750-1250 >2000 >1250

Fluticasone 100-250 100-200

>250-500 >200-500 >500 >500

Mometasone furoate 200-400 100-200

> 400-800 >200-400 >800-1200 >400

Triamcinolone acetonide 400-1000 400-800

>1000-2000 >800-1200 >2000 >1200

Component 4: Asthma Management and Prevention Program

Reliever MedicationsComponent 4: Asthma Management and Prevention Program

Reliever Medications

Rapid-acting inhaled β2-agonists

Systemic glucocorticosteroids

Anticholinergics

Theophylline

Short-acting oral β2-agonists

Rapid-acting inhaled β2-agonists

Systemic glucocorticosteroids

Anticholinergics

Theophylline

Short-acting oral β2-agonists

Component 4: Asthma Management and Prevention Program Allergen-specific Immunotherapy

Component 4: Asthma Management and Prevention Program Allergen-specific Immunotherapy

Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis

The role of specific immunotherapy in asthma is limited

Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma

Perform only by trained physician

Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis

The role of specific immunotherapy in asthma is limited

Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma

Perform only by trained physician

controlled

partly controlled

uncontrolled

exacerbation

LEVEL OF CONTROLLEVEL OF CONTROL

maintain and find lowest controlling step

consider stepping up to gain control

step up until controlled

treat as exacerbation

TREATMENT OF ACTIONTREATMENT OF ACTION

TREATMENT STEPSREDUCE INCREASE

STEP

1STEP

2STEP

3STEP

4STEP

5

RE

DU

CE

INC

RE

AS

E

Step 1 – As-needed reliever medication

Patients with occasional daytime symptoms of short duration

A rapid-acting inhaled β2-agonist is the recommended reliever treatment (Evidence A)

When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher)

Treating to Achieve Asthma Control

Step 2 – Reliever medication plus a single controller

A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (Evidence A)

Alternative controller medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids


Step 3 – Reliever medication plus one or two controllers

For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting β2-agonist either in a combination inhaler device or as separate components (Evidence A)

Inhaled long-acting β2-agonist must not be used as monotherapy

For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)


Additional Step 3 Options for Adolescents and Adults

Increase to medium-dose inhaled glucocorticosteroid (Evidence A)

Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)

Low-dose sustained-release theophylline (Evidence B)


Step 4 – Reliever medication plus two or more controllers

Selection of treatment at Step 4 depends on prior selections at Steps 2 and 3

Where possible, patients not controlled on Step 3 treatments should be referred to a health professional with expertise in the management of asthma


Step 4 – Reliever medication plus two or more controllers

Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence A)

Medium- or high-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)

Low-dose sustained-release theophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence B)



Step 5 – Reliever medication plus additional controller options

Addition of oral glucocorticosteroids to other controller medications may be effective (Evidence D) but is associated with severe side effects (Evidence A)

Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)

Treating to Maintain Asthma Control

When control as been achieved, ongoing monitoring is essential to:

- maintain control

- establish lowest step/dose treatment

Asthma control should be monitored by the health care professional and by the patient


Stepping down treatment when asthma is controlled

When controlled on medium- to high-dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals (Evidence B)

When controlled on low-dose inhaled glucocorticosteroids: switch to once-daily dosing (Evidence A)


Stepping down treatment when asthma is controlled

When controlled on combination inhaled glucocorticosteroids and long-acting inhaled β2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting β2-agonist (Evidence B)

If control is maintained, reduce to low-dose inhaled glucocorticosteroids and stop long-acting β2-agonist (Evidence D)


Stepping up treatment in response to loss of control

Rapid-onset, short-acting or long-acting inhaled β2-agonist bronchodilators provide temporary relief.

Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy


Stepping up treatment in response to loss of control

Use of a combination rapid and long-acting inhaled β2-agonist (e.g., formoterol) and an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a controller and reliever is effecting in maintaining a high level of asthma control and reduces exacerbations (Evidence A)

Doubling the dose of inhaled glucocortico-steroids is not effective, and is not recommended (Evidence A)

Childhood and adult asthma share the same underlying mechanisms. However, because of processes of growth and development, effects of asthma treatments in children differ from those in adults.

Childhood and adult asthma share the same underlying mechanisms. However, because of processes of growth and development, effects of asthma treatments in children differ from those in adults.


Component 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger



Many asthma medications (e.g. glucocorticosteroids, β2- agonists, theophylline) are metabolized faster in children than in adults, and younger children tend to metabolize medications faster than older children

Many asthma medications (e.g. glucocorticosteroids, β2- agonists, theophylline) are metabolized faster in children than in adults, and younger children tend to metabolize medications faster than older children





Long-term treatment with inhaled glucocorticosteroids has not been shown to be associated with any increase in osteoporosis or bone fracture

Studies including a total of over 3,500 children treated for periods of 1 – 13 years have found no sustained adverse effect of inhaled glucocorticosteroids on growth

Long-term treatment with inhaled glucocorticosteroids has not been shown to be associated with any increase in osteoporosis or bone fracture

Studies including a total of over 3,500 children treated for periods of 1 – 13 years have found no sustained adverse effect of inhaled glucocorticosteroids on growth





Rapid-acting inhaled β2-agonists are the most effective reliever therapy for children

These medications are the most effective bronchodilators available and are the treatment of choice for acute asthma symptoms

Rapid-acting inhaled β2-agonists are the most effective reliever therapy for children

These medications are the most effective bronchodilators available and are the treatment of choice for acute asthma symptoms





Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness

Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)

Severe exacerbations are potentially life-threatening and treatment requires close supervision

Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness

Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)

Severe exacerbations are potentially life-threatening and treatment requires close supervision


Component 4: Manage Asthma Exacerbations







Treatment of exacerbations depends on: The patient Experience of the health care professional Therapies that are the most effective for

the particular patient Availability of medications Emergency facilities

Treatment of exacerbations depends on: The patient Experience of the health care professional Therapies that are the most effective for

the particular patient Availability of medications Emergency facilities

Primary therapies for exacerbations:

• Repetitive administration of rapid-acting inhaled β2-agonist

• Early introduction of systemic glucocorticosteroids

• Oxygen supplementation

Closely monitor response to treatment with serialmeasures of lung function

Primary therapies for exacerbations:

• Repetitive administration of rapid-acting inhaled β2-agonist

• Early introduction of systemic glucocorticosteroids

• Oxygen supplementation

Closely monitor response to treatment with serialmeasures of lung function





Asthma Management and Prevention ProgramAsthma Management and Prevention Program

Special ConsiderationsAsthma Management and Prevention ProgramAsthma Management and Prevention Program

Special Considerations

Special considerations are required tomanage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma

Special considerations are required tomanage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma





Asthma Management and Prevention Program: SummaryAsthma Management and Prevention Program: Summary

A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication

The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered

A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication

The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered

Asthma Management and Prevention Program: SummaryAsthma Management and Prevention Program: Summary

Alternate Slides for Alternate Slides for Asthma TreatmentAsthma Treatment

Characteristic Controlled(All of the following)

Partly Controlled(Any measure present in any week)

Uncontrolled

Daytime symptoms None (twice or less/week)

More than twice/week

Three or more features of partly controlled asthma present in any week


None Any

Nocturnal symptoms/awakening

None Any

Need for reliever/ rescue treatment

None (twice or less/week)

More than twice/week


Normal < 80% predicted or personal best (if known)

Exacerbations None One or more/year* One in any week†


* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate.† By definition, an exacerbation in any week makes that an uncontrolled asthma week.

Asthma Control: Treatment StepsChildren Older than Five Years, Adolescents, Adults

Example Of Contents Of An Action Plan To Maintain Asthma Control

Your Regular Treatment: 1. Each day take ___________________________ 2. Before exercise, take _____________________

WHEN TO INCREASE TREATMENTAssess your level of Asthma ControlIn the past week have you had: Daytime asthma symptoms more than 2 times ? No Yes Activity or exercise limited by asthma? No Yes Waking at night because of asthma? No Yes The need to use your [rescue medication] more than 2 times? No Yes If you are monitoring peak flow, peak flow less than________? No YesIf you answered YES to three or more of these questions, your asthma is uncontrolled and you may need to step up your treatment.

HOW TO INCREASE TREATMENTSTEP-UP your treatment as follows and assess improvement every day:____________________________________________ [Write in next treatment step here] Maintain this treatment for _____________ days [specify number]

WHEN TO CALL THE DOCTOR/CLINIC.Call your doctor/clinic: _______________ [provide phone numbers]If you don’t respond in _________ days [specify number]______________________________ [optional lines for additional instruction]

EMERGENCY/SEVERE LOSS OF CONTROLIf you have severe shortness of breath, and can only speak in short sentences,If you are having a severe attack of asthma and are frightened,If you need your reliever medication more than every 4 hours and are not improving.1. Take 2 to 4 puffs ___________ [reliever medication] 2. Take ____mg of ____________ [oral glucocorticosteroid]3. Seek medical help: Go to _____________________; Address___________________ Phone: _______________________4. Continue to use your _________[reliever medication] until you are able to get medical help.

Documents

GINA Slide Set 2006