1. G IN A lobal itiative for sthma

4. United States United Kingdom Argentina Australia Brazil Austria Canada Chile Belgium China Denmark Colombia Croatia Germany Greece Ireland Italy Syria Hong Kong Japan India Korea Kyrgyzstan Moldova Macedonia Malta Netherlands New Zealand Poland Portugal Georgia Romania Russia Singapore Slovenia Saudi Arabia South Africa Spain Sweden Thailand Switzerland Ukraine Taiwan ROC Venezuela Vietnam Yugoslavia Albania Bangladesh France Mexico Turkey Czech Republic Lebanon Pakistan GINA Assembly Israel Slovakia

7. Global Strategy for Asthma Management and Prevention Evidence Category Sources of Evidence A Randomized clinical trials Rich body of data B Randomized clinical trials Limited body of data C Non-randomized trials Observational studies D Panel judgment consensus

10. Source: Peter J. Barnes, MD Asthma Inflammation: Cells and Mediators

11. Mechanisms: Asthma Inflammation Source: Peter J. Barnes, MD

12. Source: Peter J. Barnes, MD Asthma Inflammation: Cells and Mediators

14. Asthma Prevalence and Mortality Source : Masoli M et al. Allergy 2004

20. Typical Spirometric (FEV 1 ) Tracings 1 Time (sec) 2 3 4 5 FEV 1 Volume Normal Subject Asthmatic (After Bronchodilator) Asthmatic (Before Bronchodilator) Note: Each FEV 1 curve represents the highest of three repeat measurements

21. Measuring Variability of Peak Expiratory Flow

22. Measuring Airway Responsiveness

23. Intermittent Symptoms less than once a week Brief exacerbations Nocturnal symptoms not more than twice a month • FEV1 or PEF ≥ 80% predicted • PEF or FEV1 variability < 20% Mild Persistent Symptoms more than once a week but less than once a day Exacerbations may affect activity and sleep Nocturnal symptoms more than twice a month • FEV1 or PEF ≥ 80% predicted • PEF or FEV1 variability < 20 – 30%

24. Moderate Persistent Symptoms daily Exacerbations may affect activity and sleep Nocturnal symptoms more than once a week Daily use of inhaled short-acting 2-agonist • FEV1 or PEF 60-80% predicted • PEF or FEV1 variability > 30% Severe Persistent Symptoms daily Frequent exacerbations Frequent nocturnal asthma symptoms Limitation of physical activities • FEV1 or PEF ≤ 60% predicted • PEF or FEV1 variability > 30%

25. Levels of Asthma Control 3 or more features of partly controlled asthma present in any week < 80% predicted or personal best (if known) on any day Normal Lung function (PEF or FEV 1 ) One or more / year 1 in any week None Exacerbation More than twice / week None (2 or less / week) Need for rescue / “reliever” treatment Any None Nocturnal symptoms / awakening Any None Limitations of activities More than twice / week None (2 or less / week) Daytime symptoms Uncontrolled Partly controlled (Any present in any week) Controlled (All of the following) Characteristic

26. 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 Prevention Program: Five Components Revised 2006

33. Your Regular Treatment: 1. Each day take ___________________________ 2. Before exercise, take _____________________ WHEN TO INCREASE TREATMENT Assess your level of Asthma Control In 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 Yes If 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 TREATMENT STEP-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 CONTROL  If 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. Example Of Contents Of An Action Plan To Maintain Asthma Control

38. Asthma Management and Prevention Program 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

47. controlled partly controlled uncontrolled exacerbation LEVEL OF CONTROL maintain and find lowest controlling step consider stepping up to gain control step up until controlled treat as exacerbation TREATMENT OF ACTION TREATMENT STEPS REDUCE INCREASE STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 REDUCE INCREASE

66. 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. Asthma Management and Prevention Program Component 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger

67. Many asthma medications ( e.g. glucocorticosteroids, β 2 - agonists, theophylline) are metabolized faster in children than in adults, and younger children tend to metabolize medications faster than older children Asthma Management and Prevention Program Component 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger

73. THANK YOU