The document discusses asthma management guidelines and provides several case scenarios. It covers investigations for initial asthma evaluation including CBC, IgE, chest X-ray, and echocardiogram. It discusses asthma mimics, comorbidities, inhaler selection, exacerbation risk factors including viral infections, and the importance of preventing exacerbations to reduce healthcare costs and lung function decline. It also notes that referral to a dedicated asthma clinic is important.

1. ASTHMA
MANAGEMENT
AND GINA
GUIDELINES

2. CASE
SCENARIO
21yr old female
Episodic breathlessness,
sneezing and occasional
wheeze
Seasonal predilection

3. CASE
SCENARIO
6yr old boy
Chronic cough,
wheeze
Family history of
asthma

6. ASTHMA MIMICS
• Anaphylaxis, angioedema
• Central airway obstruction
• Heart failure
• Allergic reaction
• Airway foreign body
• Pulmonary embolism
• Vocal cord dysfunction
• Bronchiolitis

9. Comorbidities
• Rhinitis, Sinusitis / nasal polyps
• Obesity
• Gastro-esophageal reflux disease
• Anxiety & depression
• Food Allergy
• Obstructive sleep apnea
• Asthma-COPD overlap

10. WHAT ARE THE INVESTIGATIONS YOU
WOULD ORDER FOR AN ASTHMATIC ON
INITIAL EVALUATION

11. Usual Workup
• CBC, DLC
• IgE
• Xray Chest
• Xray PNS
• 2D ECHO/NT-ProBNP

12. ASTHMA MIMICS
• Anaphylaxis, angioedema
• Central airway obstruction
• Heart failure
• Allergic reaction
• Airway foreign body
• Pulmonary embolism
• Vocal cord dysfunction
• Bronchiolitis

13. ILC2 production of
type 2 cytokines6
Type 2–low Type 2–high
Progress in understanding of asthma phenotypes
TH2-high vs TH2-low5
Biomarkers:
IL-5, IL-4, IL-13, periostin,
eosinophils,
FeNO etc.
Asthma
population
Eosinophilic vs
non-eosinophilic3,4
Biomarker:
Sputum or blood eosinophils
Allergic1 vs non-
allergic2
Biomarker:
Skin prick tests
RAST
IgE
1. Johansson SGO, et al, Thorax 1969;24:510;
2. Khan AU, et al, Ann Allergy 1974;32:245-251;
3. Frigas E, et al, J Allergy Clin Immunol 1986;77:527-537;
4. Brown HM, Lancet 1958;2:1245-1247;
5. Robinson DS, et al, N Engl J Med 1992;326:298-304;
6. Bernink JH, et al, Curr Opin Immunol 2014;31:115-120.

14. ADVANCED LAB / IMMUNOLOGICAL TESTING
• For patients with severe persistent asthma, a CBC and differential (to evaluate
the presence/absence of eosinophils and exclude anemia as a cause of
dyspnea) and a total serum immunoglobulin E (IgE) level (eg, for allergic
bronchopulmonary aspergillosis [ABPA] or for identification of candidates for
anti-IgE therapy) are usually obtained.
• Specific testing for aspergillus sensitization (skin test or immunoassay) and an
antineutrophil cytoplasmic antibody (ANCA) are performed in those with high
blood eosinophils to evaluate for ABPA and eosinophilic granulomatosis with
polyangiitis (EGPA, Churg-Strauss), respectively

15. UPON DIAGNOSIS OF ASTHMA IN THE
ABOVE PATIENT, WHAT WOULD BE THE
FIRST CHOICE OF TREATMENT?
HOW TO DECIDE THE BEST INHALER?

16. THE BEST ONE YET!

17. 17
Factors that can influence optimal drug delivery from inhalers
Optimal
Drug
delivery
Formulation
• Efficient delivery to site of
action
• Design
• Consistent doses
• Ease of use
• Cost
• Age
• Socioeconomic condition
• Disease condition
• Personal acceptance
• Training
• Stability
• Safety
Ibrahim et al. Medical Devices: Evidence and Research 2015:8 131–139

18. 18
Reasons for poor asthma control:
incorrect choice of inhaler, poor technique
Correlation between the number of errors in inhalation
techniques and Asthma instability score. (linear
regression analysis): r=0.3, p < 0.0001.
Haughney et al. Respiratory Medicine 2008;102:1681-1693
Bjemer et al. Respiration 2014;88:346-352
Misuse of pressurised metered dose inhalers is
directly linked to decreased asthma stability
• Poor inhaler technique is a common
problem among patients with asthma
• trainers should be competent, and
inhaler technique should be rechecked
• The choice of inhaler for ICS delivery is
most important because of the greater
need to specifically and accurately
target the site of deposition

19. 19
Assess inhaler technique
• Take patient preference into account when choosing the inhaler device
• Simplify the regimen and do not mix inhaler device types
• The choice of steroid inhaler is most important because of the narrower
therapeutic window
• Invest the time to train each patient in proper inhaler technique:
– Observe technique & let patient observe self (using video demonstrations)
– Devices to check technique & maintain trained technique are available
• Recheck inhaler technique on each revisit
GINA Global Initiative for Asthma Guidelines: 2018

22. CASE
SCENARIO
• Middle aged male
• On regular ICS/LABA
• Regular follow up
• Comes back within
3weeks with night
awakenings

23. Low dose ICS whenever
SABA taken, or daily LTRA,
or add HDM SLIT
Medium dose ICS, or
add LTRA, or add
HDM SLIT
Add LAMA or LTRA or
HDM SLIT, or switch to
high dose ICS
Add azithromycin (adults) or
LTRA. As last resort consider
adding low dose OCS but
consider side-effects
RELIEVER: As-needed short-acting beta2-agonist
STEP 1
Take ICS whenever
SABA taken
STEP 2
Low dose
maintenance ICS
STEP 3
Low dose
maintenance
ICS-LABA
STEP 4
Medium/high
dose maintenance
ICS-LABA
STEP 5
Add-on LAMA
Refer for assessment
of phenotype. Consider
high dose maintenance
ICS-LABA, ± anti-IgE,
anti-IL5/5R, anti-IL4R,
anti-TSLP
RELIEVER: As-needed low-dose ICS-formoterol
STEPS 1 – 2
As-needed low dose ICS-formoterol
STEP 3
Low dose
maintenance
ICS-formoterol
STEP 4
Medium dose
maintenance
ICS-formoterol
STEP 5
Add-on LAMA
Refer for assessment
of phenotype. Consider
high dose maintenance
ICS-formoterol,
± anti-IgE, anti-IL5/5R,
anti-IL4R, anti-TSLP
Treatment of modifiable risk factors
and comorbidities
Non-pharmacological strategies
Asthma medications (adjust down/up/between tracks)
Education & skills training
Adults & adolescents
12+ years
Personalized asthma management
Assess, Adjust, Review
for individual patient needs
Symptoms
Exacerbations
Side-effects
Lung function
Patient satisfaction
Confirmation of diagnosis if necessary
Symptom control & modifiable
risk factors (see Box 2-2B)
Comorbidities
Inhaler technique & adherence
Patient preferences and goals
CONTROLLER and
PREFERRED RELIEVER
(Track 1). Using ICS-formoterol
as reliever reduces the risk of
exacerbations compared with
using a SABA reliever
Other controller options for either
track (limited indications, or less
evidence for efficacy or safety)
CONTROLLER and
ALTERNATIVE RELIEVER
(Track 2). Before considering a
regimen with SABA reliever,
check if the patient is likely to be
adherent with daily controller
See GINA
severe
asthma guide
© Global Initiative for Asthma, www.ginasthma.org
GINA 2022, Box 3-5A

25. Comorbidities
• Rhinitis, Sinusitis / nasal polyps
• Obesity
• Gastro-esophageal reflux disease
• Anxiety & depression
• Food Allergy
• Obstructive sleep apnea
• Asthma-COPD overlap

26. WHAT IS A GOOD TIME TO DECREASE
THERAPY?

28. HOW CAN WE PREDICT FUTURE
RISK OF EXACERBATIONS?

29. WHY IS IT IMPORTANT TO PREVENT
EXACERBATIONS?
1. Cost to patient and healthcare system
2. To prevent Lung function decline
3. Improve quality of life
4. All of above

30. Bai TR, et al. Eur Respir J 2007; 30:452-6
>0.10 exacerbations/yr n = 47
Decline in FEV1 31.5 ml/yr (95%CI 18.2; 44.8)
< 0.10 exacerbations/yr n = 46
Decline in FEV1 14.6 ml/yr (95%CI 1.9; 27.1)
Image is used for educational purpose only. AstraZeneca is not responsible for data and copyrights

31. Revised Treatment Approach
Current Control
Achieve and maintain best
possible clinical control
Symptoms
Activity
Reliever use
Lung function
defined by
1
Future Risk
Instability/
Worsening
Loss
of lung function
Exacerbations
Adverse effects
of Medication
defined by
Target: Reduction of risk
2
2a Treatments that do not require phenotyping
2b Treatments on the basis of inflammatory phenotyping
Based on Bateman ED. J Allergy Clin Immunol 2010;125:600–8.

32. Complementary roles of LABA and ICS in achieving
and maintaining asthma control
Controlled asthma
Partly
controlled
asthma
Uncontrolled
asthma
Severe exacerbations
Extra ICS
Addition of LABA
Extra ICS
Extra LABA
Partly controlled
asthma
Pauwels RA et al. N Engl J Med 1997; 337: 1405–11.

34. WHEN SHOULD A PATIENT BE
REFERRED TO A DEDICATED
ASTHMA CLINIC?
IS IT THAT IMPORTANT?

36. WHAT IS THE RELATION OF
ASTHMA WITH COVID
DO WE VACCINATE?

37. Factors that contribute to asthma exacerbations
Viral respiratory infections
Allergen exposure
Air pollution
Exercise / Cold air
Stress
Bacterial infections
Occupational exposures

38. Role of viral respiratory infections in asthma exacerbations
• 80 to 85% are associated with viral infections (URTI’s)
• Any viral respiratory pathogen (e.g. RSV, parainfluenza)
can precipitate attacks
• Rhinoviruses (especially Types A and C) are most
common cause
• Seasonal patterns of infections correlate with hospital
admissions (Spring and autumn peaks)
Johnston SL, el al. BMJ 1995;310:1225-9.
Johnston SL, et al. Am J Respir Crit Care Med 1996;154:656-60.