Guias Gina y Practall

1. Guías GINA y PRACTALL
Residente: Dr. Mauricio Gerardo Ochoa Montemayor
Asesor: Dra. Alejandra Macías Weinmann

2. Definición, descripción y
diagnóstico
Dr. Ochoa
CRAIC Mty

3. Introducción
 El asma es un problema de salud global que afecta todos
los grupos de edades, con prevalencia en aumento,
especialmente en niños.
 En 1993 el National Heart, Lung and Blood Institute en
colaboración con la Organización Mundial de la Salud
creó el informe ‘Estrategia Global para el Tratamiento y la
Prevención del Asma´.
 Tras ello se formó la Iniciativa Global para el Asma
(GINA)
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

4. Definición
 El asma es una enfermedad heterogénea, caracterizada
por una inflamación crónica de las vías aéreas.
 Se define por síntomas respiratorios como sibilancias,
dificultad respiratoria, opresión torácica y tos, con una
limitación variable del flujo aéreo espiratorio.
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

5. Descripción del asma
 Es una enfermedad crónica común que afecta 1-18% de la
población
 Síntomas variables de disnea, sibilancias, opresión torácica
y tos con limitación variable del flujo aéreo espiratorio
 Desencadenada por factores como ejercicio, alérgenos,
infecciones, etc.
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

6. Criterios diagnósticos
 Antecedentes de sibilancias, opresión torácica, tos, disnea
 Más de un síntoma respiratorio
 Ocurren con tiempo e intensidad variable
 Empeoran en la noche o al despertar
 Desencadenadas por ejercicio, risa, alérgenos, frío
 Empeoran con infecciones
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

7. Criterios diagnósticos
 Reversibilidad con broncodilatador
 Exceso de variabilidad 2 veces al vía por dos semanas
>10% en adultos, >13% en niños
 Mejoría en función pulmonar después de 4 semanas de
antiinflamatorio
 Prueba de esfuerzo positiva
 Prueba de reto bronquial positiva
 Exceso de variación entre función pulmonar entre
consultas
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

8. Diagnóstico
 Antecedentes personales y familiares
 Exploración física
 Pruebas de función pulmonar para documentar
variabilidad en flujo espiratorio
 Otras pruebas:
 Test de provocación bronquial
 Pruebas de alergia
 FENO
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

9. Diagnósticos diferenciales
Dr. Ochoa
CRAIC Mty

10. Diagnóstico en poblaciones especiales
 Tos como único síntoma
 Considerar:
 Variante tos
 IECA
 ERGE
 Sinusitis crónica
 Disfunción de cuerdas vocales
 Documentar variabilidad en función pulmonar
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

11. Diagnóstico en poblaciones especiales
 Asma ocupacional
 Inducida o agravada por alérgenos
 5-20% de asma de inicio en adultos
 Interrogar síntomas fuera del trabajo
 Atletas
 Confirmar con pruebas de función pulmonar
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

12. Diagnóstico en poblaciones especiales
 Tercera edad
 Pobre percepción de limitación del flujo aéreo
 Disnea “normal”
 Actividad física disminuida
 Comorbilidades
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

13. Patrones de sibilancias
 Transitorias
 No-atópicas
 Asma persistente
 Sibilancias intermitentes
graves
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al.Allergy.Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty

14. Factores determinantes
 Factores genéticos
 Ambiente y estilo de vida
 Aeroalérgenos
 Alergias alimentarias
 Infección
 Humo de tabaco
 Contaminación
 Nutrición
 Ejercicio
 Clima
 Estrés
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al.Allergy.Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty

15. Elementos que definen fenotipo
 Edad
 Lactantes
 Preescolares
 Escolares
 Adolescentes
 Gravedad
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al.Allergy.Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty

16. Fisiopatología
 Anomalías inmunológicas
 Inmunidad de célulasT
 Atopia
 Remodelación de la vía aérea
 Inflamación bronquial
 Inflamación nasal
 Epitelio
 Células inflamatorias
 Obstrucción de la vía aérea
 Hiperreactividad
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al.Allergy.Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty

17. Diagnóstico
 Historia clínica
 Frecuencia y gravedad de los síntomas
 Patrón de los síntomas
 Confirmación de sibilancias por el médico
 Interrogar sobre
 Tos, sibilancias
 Relación causal
 Patrón de sueño
 Exacerbaciones
 Síntomas nasales
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al.Allergy.Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty

18. Diagnóstico
 Lactantes
 Ruidos al respirar
 Vómito asociado a la tos
 Retracción
 Dificultad para la alimentación
 Cambios en la frecuencia respiratoria
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al.Allergy.Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty

19. Diagnóstico
 Niños mayores de 2 años
 Disnea
 Fatiga
 Malestar
 Desempeño escolar
 Desempeño en actividad física
 Evita actividades
 Relación causal
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al.Allergy.Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty

20. Evaluación del asma
Dr. Ochoa
CRAIC Mty

21. Evaluación del asma
 Control: Grado en el cual las manifestaciones se observan
en el paciente o se reducen/desaparecen con el
tratamiento.
 Tiene dos componentes
 Control de los síntomas
 Riesgo de resultados adversos
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

22. Evaluación de control de los síntomas
 Los síntomas varían en intensidad y frecuencia,
contribuyendo a la carga para el paciente.
 El mal control se asocia fuertemente con un aumento en
el riesgo de exacerbaciones
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

23. Herramientas para evaluar control del asma
 Asthma Control Questionnaire (ACQ)
 Valores de 0-6
 0 – 0.75: bien controlada
 >1.5: con pobre control
 Asthma ControlTest (ACT)
 Valores de 5-25
 20-25: bien controlada
 16-19: parcialmente controlada
 5-15: con pobre control
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

24. A. Symptom control
In the past 4 weeks, has the patient had:
Well-
controlled
Partly
controlled
Uncontrolled
• Daytime asthma symptoms more
than twice a week? Yes No
None of
these
1-2 of
these
3-4 of
these
• Any night waking due to asthma? Yes No
• Reliever needed for symptoms*
more than twice a week? Yes No
• Any activity limitation due to asthma? Yes No
Dr. Ochoa
CRAIC Mty

25. Evaluar el riesgo a futuro
 FEV1 disminuido
 Identifica pacientes con mayor riesgo de exacerbaciones
(<60%)
 Inflamación no tratada
 FEV1 normal o aumentado
 Considerar otras causas
 Reversibilidad persistente
 Mal control
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

26. © Global Initiative for Asthma
Assessment of risk factors for poor asthma
outcomes
GINA 2015, Box 2-2B (4/4)
Risk factors for exacerbations include:
• Ever intubated for asthma
• Uncontrolled asthma symptoms
• Having ≥1 exacerbation in last 12 months
• Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)
• Incorrect inhaler technique and/or poor adherence
• Smoking
• Obesity, pregnancy, blood eosinophilia
Risk factors for fixed airflow limitation include:
• No ICS treatment, smoking, occupational exposure, mucus
hypersecretion, blood eosinophilia
Risk factors for medication side-effects include:
• Frequent oral steroids, high dose/potent ICS, P450 inhibitors
Dr. Ochoa
CRAIC Mty

27. Gravedad del asma
 Se evalúa de manera retrospectiva
 Leve: paso 1, 2
 Moderada: paso 3
 Grave: paso 4 o 5
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

28. Asma grave VS no controlada
 Técnica de inhalador (80%)
 Apego
 Diagnóstico incorrecto
 Comorbilidades
 Exposición al medio ambiente
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

29. Tratamiento para controlar
síntomas y disminuir riesgo
Dr. Ochoa
CRAIC Mty

30. Tratamiento
 Metas
 Alcanzar buen control de los síntomas y mantener un nivel
normal de actividades diarias
 Disminuir el riesgo de exacerbaciones, limitación del flujo
aéreo, efectos adversos
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

31. Ciclo de tratamiento
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function
Dr. Ochoa
CRAIC Mty

32. Tratamiento
 Criterios para elección
 Poblacionales
 Paciente
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

33. Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

34. *For children 6-11 years,
theophylline is not
recommended, and preferred
Step 3 is medium dose ICS
**For patients prescribed
BDP/formoterol or BUD/
formoterol maintenance and
reliever therapy
# Tiotropium by soft-mist
inhaler is indicated as add-on
treatment for adults
(≥18 yrs) with a history of
exacerbations
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function
Other
controller
options
RELIEVER
STEP 1 STEP 2
STEP 3
STEP 4
STEP 5
Low dose ICS
Considerlow
dose ICS
Leukotriene receptor antagonists (LTRA)
Low dose theophylline*
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
As-needed short-acting beta2-agonist (SABA) As-needed SABA or
low dose ICS/formoterol**
Low dose
ICS/LABA*
Med/high
ICS/LABA
Refer for
add-on
treatment
e.g.
anti-IgE
PREFERRED
CONTROLLER
CHOICE
Add tiotropium#
High dose ICS
+ LTRA
(or + theoph*)
Add
tiotropium#
Add low
dose OCS
Dr. Ochoa
CRAIC Mty

35. Revisión y ajuste de tratamiento
 Beneficio total a los 3-4 meses de tratamiento
 Evaluar en cada visita, frecuencia según el paciente
 Incremento
 Sostenido (2-3 meses)
 Corto plazo (1-2 semanas)
 Día a día
 Descenso
 Se puede reducir al lograr control por 3 meses
 Metas
 Encontrar el tratamiento mínimo efectivo
 Estimular al paciente para continuar un control regular
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

36. Tratamiento no farmacológico
 Cesar el tabaquismo
 Actividad física
 Control de medio ambiente
 Uso de medicamentos
 Dieta
 Control de peso
 Vacunación
 Control de estrés
 Inmunoterapia
 Evitar alérgenos (intra/extramuros)
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

37. Comorbilidades
 Obesidad
 ERGE
 Ansiedad/depresión
 Alergia alimentaria/anafilaxia
 Rinitis, sinusitis y pólipos nasales
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

38. Tratando poblaciones especiales
 Adolescentes
 Broncoconstricción inducida por el ejercicio
 Atletas
 Embarazo
 Asma ocupacional
 Tercera edad
 Procedimientos quirúrgicos
 Enfermedad respiratoria exacerbada por aspirina
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

39. Diagnóstico de asma, EPOC y
ACOS
Dr. Ochoa
CRAIC Mty

40. Definiciones
 EPOC: Enfermedad común prevenible y tratable
caracterizada por limitación del flujo aéreo persistente
progresivo asociado a respuestas inflamatorias crónicas
incrementadas por partículas o gases nocivos.
 Asthma-COPD overlap syndrome (ACOS): Limitación del
flujo aéreo persistente con características asociadas a
asma y características asociadas a EPOC.
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

41. Abordaje diagnóstico por pasos
 Paso 1: ¿El paciente tiene enfermedad respiratoria
crónica?
 Historia clínica
 Exploración física
 Radiografías
 Cuestionarios
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

42. Abordaje diagnóstico por pasos
 Paso 2: Diagnóstico sindromático
 Reunir características que apoyen diagnóstico de asma o EPOC
 Comparar entre asma y EPOC
 Considerar el nivel de certeza de diagnóstico de asma o
COPD
 Paso 3: Espirometría
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

43. © Global Initiative for AsthmaGINA 2014 © Global Initiative for AsthmaGINA 2015, Box 5-4
SYNDROMIC DIAGNOSIS IN ADULTS
(i) Assemble the features for asthma and for COPD that best describe the patient.
(ii) Compare number of features in favour of each diagnosis and select a diagnosis
STEP 2
Features: if present suggest - ASTHMA COPD
Age of onset  Before age 20 years  After age 40 years
Pattern of symptoms  Variation over minutes, hours or days
 Worse during the night or early morning
 Triggered by exercise, emotions
including laughter, dust or exposure
to allergens
 Persistent despite treatment
 Good and bad days but always daily
symptoms and exertional dyspnea
 Chronic cough & sputum preceded
onset of dyspnea, unrelated to triggers
Lung function  Record of variable airflow limitation
(spirometry or peak flow)
 Record of persistent airflow limitation
(FEV1/FVC < 0.7 post-BD)
Lung function between
symptoms
 Normal  Abnormal
Past history or family history  Previous doctor diagnosis of asthma
 Family history of asthma, and other
allergic conditions (allergic rhinitis or
eczema)
 Previous doctor diagnosis of COPD,
chronic bronchitis or emphysema
 Heavy exposure to risk factor: tobacco
smoke, biomass fuels
Time course  No worsening of symptoms over time.
Variation in symptoms either
seasonally, or from year to year
 May improve spontaneously or have
an immediate response to
bronchodilators or to ICS over weeks
 Symptoms slowly worsening over time
(progressive course over years)
 Rapid-acting bronchodilator treatment
provides only limited relief
Chest X-ray  Normal  Severe hyperinflation
DIAGNOSIS
CONFIDENCE IN
DIAGNOSIS
Asthma
Asthma
Some features
of asthma
Asthma
Features of
both
Could be ACOS
Some features
of COPD
Possibly COPD
COPD
COPD
NOTE: • These features best distinguish between asthma and COPD. • Several positive features (3 or more) for either asthma or COPD suggest
that diagnosis. • If there are a similar number for both asthma and COPD, consider diagnosis of ACOS
Dr. Ochoa
CRAIC Mty

44. © Global Initiative for Asthma
Step 3 - Spirometry
Spirometric variable Asthma COPD ACOS
Normal FEV1/FVC
pre- or post-BD
Compatible with asthma Not compatible with
diagnosis (GOLD)
Not compatible unless
other evidence of chronic
airflow limitation
FEV1 ≥80% predicted Compatible with asthma
(good control, or interval
between symptoms)
Compatible with GOLD
category A or B if post-
BD FEV1/FVC <0.7
Compatible with mild
ACOS
Post-BD increase in
FEV1 >12% and 400mL
from baseline
- High probability of
asthma
Unusual in COPD.
Consider ACOS
Compatible with
diagnosis of ACOS
Post-BD FEV1/FVC <0.7- Indicates airflow
limitation; may improve
Required for diagnosis
by GOLD criteria
Usual in ACOS
Post-BD increase in
FEV1 >12% and 200mL
from baseline (reversible
airflow limitation)
- Usual at some time in
course of asthma; not
always present
Common in COPD and
more likely when FEV1
is low
Common in ACOS, and
more likely when FEV1 is
low
FEV1<80% predicted Compatible with asthma.
A risk factor for
exacerbations
Indicates severity of
airflow limitation and risk
of exacerbations and
mortality
Indicates severity of
airflow limitation and risk
of exacerbations and
mortality
GINA 2015, Box 5-3
Dr. Ochoa
CRAIC Mty

45. Abordaje diagnóstico por pasos
 Paso 4: Iniciar tratamiento
 Si apoya asma como diagnóstico único
 Iniciar tratamiento según estrategia de GINA
 Si apoya EPOC como diagnóstico único
 Iniciar tratamiento según reporte de GOLD
 ACOS
 Tratamiento para asma de manera inicial
 Corticoesteroide inhalado a dosis bajas
 Agregar LABA o LAMA
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

46. Abordaje diagnóstico por pasos
 Paso 5: Referir para investigaciones especializadas
 Pacientes con síntomas persistentes a pesar del tratamiento
 Incertidumbre diagnóstica
 Sospecha de un diagnóstico pulmonar adicional
 Enfermedad crónica con poca evidencia de asma o EPOC
 Pacientes con comorbilidades
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

47. Diagnóstico y tratamiento de asma
en niños de 5 años y menores
Dr. Ochoa
CRAIC Mty

48. Diagnóstico
 Asma y sibilancias en niños
 El asma es la enfermedad crónica de la infancia más común,
siendo la primera causa de morbilidad infantil.
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

49. Diagnóstico
 Inducida por virus
 Sibilancias recurrentes en niños
 Asociadas a IVRS (6-8/año)
 Fenotipos de sibilancias
 Basado en síntomas
 Sibilancias episódicas o por múltiples desencadenantes
 Basado en tiempo
 Transitorios (inicio y fin antes de los 3 años), persistentes (antes de
los 3 hasta después de los 6) e inicio tardío (después de los 3)
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

50. © Global Initiative for Asthma
Features suggesting asthma in children ≤5 years
Feature Characteristics suggesting asthma
Cough Recurrent or persistent non-productive cough that may be worse at
night or accompanied by some wheezing and breathing difficulties.
Cough occurring with exercise, laughing, crying or exposure to
tobacco smoke in the absence of an apparent respiratory infection
Wheezing Recurrent wheezing, including during sleep or with triggers such as
activity, laughing, crying or exposure to tobacco smoke or air pollution
Difficult or heavy
breathing or
shortness of breath
Occurring with exercise, laughing, or crying
Reduced activity Not running, playing or laughing at the same intensity as other
children; tires earlier during walks (wants to be carried)
Past or family history Other allergic disease (atopic dermatitis or allergic rhinitis)
Asthma in first-degree relatives
Therapeutic trial with
low dose ICS and
as-needed SABA
Clinical improvement during 2–3 months of controller treatment and
worsening when treatment is stopped
GINA 2015, Box 6-2
Dr. Ochoa
CRAIC Mty

51. Pruebas adicionales
 Prueba terapéutica
 Pruebas de atopia
 Radiografía de tórax
 Pruebas de función pulmonar
 FENO
 Perfil de riesgo (API)
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

52. Diagnósticos diferenciales
 Buscar otro diagnóstico en caso de encontrar:
 Falla en el crecimiento
 Inicio muy temprano de los síntomas
 Vómito y síntomas respiratorios
 Sibilancias continuas
 Respuesta nula al tratamiento
 Sin asociación a desencadenantes (IVRS)
 Signos focales pulmonares o cardiovasculares
 Hipoxemia fuera de infecciones virales
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

53. © Global Initiative for Asthma
Features suggesting asthma in children ≤5 years
Feature Characteristics suggesting asthma
Cough Recurrent or persistent non-productive cough that may be worse at
night or accompanied by some wheezing and breathing difficulties.
Cough occurring with exercise, laughing, crying or exposure to
tobacco smoke in the absence of an apparent respiratory infection
Wheezing Recurrent wheezing, including during sleep or with triggers such as
activity, laughing, crying or exposure to tobacco smoke or air pollution
Difficult or heavy
breathing or
shortness of breath
Occurring with exercise, laughing, or crying
Reduced activity Not running, playing or laughing at the same intensity as other
children; tires earlier during walks (wants to be carried)
Past or family history Other allergic disease (atopic dermatitis or allergic rhinitis)
Asthma in first-degree relatives
Therapeutic trial with
low dose ICS and
as-needed SABA
Clinical improvement during 2–3 months of controller treatment and
worsening when treatment is stopped
GINA 2015, Box 6-2
Dr. Ochoa
CRAIC Mty

54. © Global Initiative for Asthma
Common differential diagnoses of asthma in
children ≤5 years
Condition Typical features
Recurrent viral respiratory
infections
Mainly cough, runny congested nose for <10 days; wheeze
usually mild; no symptoms between infections
Gastroesophageal reflux Cough when feeding; recurrent chest infections; vomits easily
especially after large feeds; poor response to asthma
medications
Foreign body aspiration Episode of abrupt severe cough and/or stridor during eating or
play; recurrent chest infections and cough; focal lung signs
Tracheomalacia or
bronchomalacia
Noisy breathing when crying or eating, or during URTIs; harsh
cough; inspiratory or expiratory retraction; symptoms often
present since birth; poor response to asthma treatment
Tuberculosis Persistent noisy respirations and cough; fever unresponsive to
normal antibiotics; enlarged lymph nodes; poor response to BD
or ICS; contact with someone with TB
Congenital heart disease Cardiac murmur; cyanosis when eating; failure to thrive;
tachycardia; tachypnea or hepatomegaly; poor response to
asthma medications
GINA 2015, Box 6-3 (1/2)
Dr. Ochoa
CRAIC Mty

55. Tratamiento
Infrequent
viral wheezing
and no or
few interval
symptoms
Symptom pattern consistent with asthma
and asthma symptoms not well-controlled, or
≥3 exacerbations per year
Symptom pattern not consistent with asthma but
wheezing episodes occur frequently, e.g. every
6–8 weeks.
Give diagnostic trial for 3 months.
Asthma diagnosis, and
not well-controlled on
low dose ICS
Not well-
controlled
on double
ICS
First check diagnosis, inhaler skills,
adherence, exposures
CONSIDER
THIS STEP FOR
CHILDREN WITH:
RELIEVER
Other
controller
options
PREFERRED
CONTROLLER
CHOICE
As-needed short-acting beta2-agonist (all children)
Leukotriene receptor antagonist (LTRA)
Intermittent ICS
Low dose ICS + LTRA Add LTRA
Inc. ICS
frequency
Add intermitt ICS
Daily low dose ICS
Double
‘low dose’
ICS
Continue
controller
& refer for
specialist
assessment
STEP 1 STEP 2
STEP 3
STEP 4
Dr. Ochoa
CRAIC Mty

56. Dosis de corticosteroides inhalados
Inhaled corticosteroid Low daily dose (mcg)
Beclometasone dipropionate (HFA) 100
Budesonide (pMDI + spacer) 200
Budesonide (nebulizer) 500
Fluticasone propionate (HFA) 100
Ciclesonide 160
Mometasone furoate Not studied below age 4 years
Triamcinolone acetonide Not studied in this age group
Dr. Ochoa
CRAIC Mty

57. Tratamiento inicial
 SABA con espaciador
 Corticoesteroides iniciados por el familiar
 Antagonista de receptores de leucotrienos.
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty

58. Algoritmo de
tratamiento de
niños mayores
de 2 años
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B.
Bacharier et al.Allergy.Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty

59. Tratamiento
 Menores de 2 años
 Existe información muy limitada, por lo que el diagnóstico y
tratamiento es difícil.
 Una revisión de Cochrane no encontró evidencia clara del
beneficio de tratamiento con B2-agonistas, con información en
conflicto en otros estudios.
 Estudios aleatorizados doble-ciego en lactantes con asma leve
persistente o grave con corticoesteroides nebulizados
demostraron menos síntomas nocturnos y menos
exacerbaciones.
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al.Allergy.Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty

60. Dr. Ochoa
CRAIC Mty
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al.Allergy.Volume 63 Issue 1 Page 5-34, January 2008

61. Dr. Ochoa
CRAIC Mty
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al.Allergy.Volume 63 Issue 1 Page 5-34, January 2008

62. Dr. Ochoa
CRAIC Mty
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al.Allergy.Volume 63 Issue 1 Page 5-34, January 2008