This document provides a summary of asthma management and prevention guidelines. It discusses diagnosing asthma based on symptoms and lung function tests. Asthma is classified by level of control into controlled, partly controlled, and uncontrolled. The four components of effective asthma care are outlined as developing a patient-doctor partnership, identifying and reducing risk factors, assessing and treating asthma, and managing exacerbations. Key aspects of each component are defined, such as developing a written asthma action plan and using inhaled corticosteroids appropriately based on control level. Treatment goals are to achieve good control to prevent symptoms and exacerbations.
This document provides a summary of asthma management and prevention guidelines from the Global Initiative for Asthma (GINA). It discusses diagnosing asthma based on symptoms and lung function tests. It classifies asthma control into controlled, partly controlled, and uncontrolled. It outlines four components of asthma care: developing a patient-doctor partnership through education and action plans; identifying and reducing risk factors; assessing, treating, and monitoring asthma; and managing exacerbations. Treatment is based on a stepwise approach to achieve control. The document provides guidance on special considerations, medications, and references other GINA resources.
RI
The patient/doctor partnership involves:
NO
1. Educating patients about asthma and its management
2. Developing an agreed written asthma action plan
3. Monitoring the patient's level of control and adjusting treatment accordingly
TE
The key elements of the patient/doctor partnership are educating patients about asthma and
its management, developing an agreed upon written asthma action plan, and monitoring the
patient's level of control and adjusting treatment accordingly.
MA
Component 2: Identify and Reduce Exposure to Risk Factors
D
Common risk factors that can trigger asthma symptoms or exacerbations should be identified
and avoided or reduced. Strategies include controlling
Gina pocket guide for asthma management 2013Marko Parra
MA
The document outlines the four components of asthma care: developing a patient-doctor partnership; identifying and reducing risk factors; assessing, treating, and monitoring asthma; and managing exacerbations. It provides guidance on diagnosing asthma, classifying asthma control, developing action plans, using medications appropriately, and addressing special considerations. The overall goal is to help patients achieve and maintain control of their asthma.
This document provides a summary of guidelines for diagnosing and managing asthma. It discusses how asthma is a chronic inflammatory disease characterized by variable respiratory symptoms and airflow limitation. The diagnosis of asthma involves assessing a patient's history and symptoms, performing a physical exam, and ruling out alternative diagnoses. Treatment involves a stepwise approach using controller medications such as inhaled corticosteroids to control symptoms and reduce the risk of exacerbations. With proper treatment, most asthma patients can achieve good control of their condition.
Guides for asthma management and prevention for children 5 and younger(be a g...Hussain Okairy
This document provides guidance for healthcare professionals on diagnosing and managing asthma in children aged 5 years and younger. Asthma is common in childhood, but can be difficult to diagnose in young children due to frequent wheezing from other causes. The diagnosis is based on recurrent symptoms like wheezing and cough in response to triggers. Treatment follows a stepwise approach starting with education and environmental control, and adding low-dose inhaled corticosteroids as needed to control symptoms and prevent exacerbations. Acute exacerbations should be treated promptly at home or in primary care to avoid hospitalization.
This document provides a summary of the 2015 Global Strategy for Asthma Management and Prevention report published by the Global Initiative for Asthma (GINA). It outlines the methodology used in developing the report, lists the key changes from the previous version, and provides the table of contents. The report aims to provide evidence-based recommendations for asthma diagnosis and management to help improve patient care worldwide. It is developed by international experts on GINA committees and is updated annually based on the latest scientific evidence.
The Global Initiative for Asthma (GINA) aims to increase awareness of asthma as a global health problem, present recommendations for diagnosis and management, and provide strategies to adapt recommendations based on varying resources. GINA works with a global network to disseminate asthma programs. The key documents produced by GINA include the Global Strategy for Asthma Management and Prevention, which provides an evidence-based framework for diagnosis, treatment, and prevention of asthma. The strategy emphasizes a stepwise approach and partnership between patients and healthcare providers to achieve optimal asthma control and management.
This document provides a pocket guide for physicians and nurses on asthma management and prevention. It discusses diagnosing asthma based on symptoms of variable respiratory symptoms and expiratory airflow limitation. It provides criteria for diagnosing asthma, including documenting reversibility of airflow limitation. It also discusses assessing asthma control, determining level of symptom control and future risk factors. Treatment is based on a stepwise approach to gain and maintain control of symptoms and minimize future risk.
This document provides a summary of asthma management and prevention guidelines from the Global Initiative for Asthma (GINA). It discusses diagnosing asthma based on symptoms and lung function tests. It classifies asthma control into controlled, partly controlled, and uncontrolled. It outlines four components of asthma care: developing a patient-doctor partnership through education and action plans; identifying and reducing risk factors; assessing, treating, and monitoring asthma; and managing exacerbations. Treatment is based on a stepwise approach to achieve control. The document provides guidance on special considerations, medications, and references other GINA resources.
RI
The patient/doctor partnership involves:
NO
1. Educating patients about asthma and its management
2. Developing an agreed written asthma action plan
3. Monitoring the patient's level of control and adjusting treatment accordingly
TE
The key elements of the patient/doctor partnership are educating patients about asthma and
its management, developing an agreed upon written asthma action plan, and monitoring the
patient's level of control and adjusting treatment accordingly.
MA
Component 2: Identify and Reduce Exposure to Risk Factors
D
Common risk factors that can trigger asthma symptoms or exacerbations should be identified
and avoided or reduced. Strategies include controlling
Gina pocket guide for asthma management 2013Marko Parra
MA
The document outlines the four components of asthma care: developing a patient-doctor partnership; identifying and reducing risk factors; assessing, treating, and monitoring asthma; and managing exacerbations. It provides guidance on diagnosing asthma, classifying asthma control, developing action plans, using medications appropriately, and addressing special considerations. The overall goal is to help patients achieve and maintain control of their asthma.
This document provides a summary of guidelines for diagnosing and managing asthma. It discusses how asthma is a chronic inflammatory disease characterized by variable respiratory symptoms and airflow limitation. The diagnosis of asthma involves assessing a patient's history and symptoms, performing a physical exam, and ruling out alternative diagnoses. Treatment involves a stepwise approach using controller medications such as inhaled corticosteroids to control symptoms and reduce the risk of exacerbations. With proper treatment, most asthma patients can achieve good control of their condition.
Guides for asthma management and prevention for children 5 and younger(be a g...Hussain Okairy
This document provides guidance for healthcare professionals on diagnosing and managing asthma in children aged 5 years and younger. Asthma is common in childhood, but can be difficult to diagnose in young children due to frequent wheezing from other causes. The diagnosis is based on recurrent symptoms like wheezing and cough in response to triggers. Treatment follows a stepwise approach starting with education and environmental control, and adding low-dose inhaled corticosteroids as needed to control symptoms and prevent exacerbations. Acute exacerbations should be treated promptly at home or in primary care to avoid hospitalization.
This document provides a summary of the 2015 Global Strategy for Asthma Management and Prevention report published by the Global Initiative for Asthma (GINA). It outlines the methodology used in developing the report, lists the key changes from the previous version, and provides the table of contents. The report aims to provide evidence-based recommendations for asthma diagnosis and management to help improve patient care worldwide. It is developed by international experts on GINA committees and is updated annually based on the latest scientific evidence.
The Global Initiative for Asthma (GINA) aims to increase awareness of asthma as a global health problem, present recommendations for diagnosis and management, and provide strategies to adapt recommendations based on varying resources. GINA works with a global network to disseminate asthma programs. The key documents produced by GINA include the Global Strategy for Asthma Management and Prevention, which provides an evidence-based framework for diagnosis, treatment, and prevention of asthma. The strategy emphasizes a stepwise approach and partnership between patients and healthcare providers to achieve optimal asthma control and management.
This document provides a pocket guide for physicians and nurses on asthma management and prevention. It discusses diagnosing asthma based on symptoms of variable respiratory symptoms and expiratory airflow limitation. It provides criteria for diagnosing asthma, including documenting reversibility of airflow limitation. It also discusses assessing asthma control, determining level of symptom control and future risk factors. Treatment is based on a stepwise approach to gain and maintain control of symptoms and minimize future risk.
This document provides an overview of the Global Initiative for Asthma (GINA) 2017 update. It outlines GINA's structure, objectives, and resources. Key points include:
- GINA aims to provide global asthma strategy recommendations for diagnosis, management, and prevention.
- It has a board of directors, science committee, and assembly of participating countries.
- Resources include the full GINA strategy report, pocket guides, and dissemination tools available on their website.
- The 2017 update focuses on areas like the asthma-COPD overlap, lung function assessments, FeNO measurements, and immunotherapy.
1) The study compared the efficacy of fluticasone propionate alone or in combination with salmeterol in achieving asthma control as defined by guidelines over 1 year in 3,421 patients with uncontrolled asthma.
2) Treatment was stepped up until total control was achieved or the maximum dose was reached, and significantly more patients achieved total and well-controlled asthma with salmeterol/fluticasone than with fluticasone alone.
3) The study confirms that guideline-defined asthma control can be achieved in the majority of patients through aggressive dose titration of controller medications.
This slide set provides an overview of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for chronic obstructive pulmonary disease (COPD). It defines COPD as a common lung disease characterized by airflow limitation caused by exposure to noxious particles or gases. The slide set outlines the GOLD board of directors and science committee, lists national leaders, and describes the objectives, evidence levels, and chapters covered in the 2017 GOLD report on defining, diagnosing, preventing, and managing COPD.
This document summarizes a meeting of the Asthma-COPD Overlap Working Group. The group discussed current and future projects on defining and studying Asthma-COPD Overlap (ACO). Their current project examines how ACO prevalence varies depending on the population definition used within a UK database. Future projects proposed examining ACO definitions across other databases and comparing outcomes for patients with ACO versus COPD. The group prioritized repeating their analyses in other databases as Phase 1 and studying patient outcomes as Phase 2. They discussed logistics of sharing data and analysis scripts between researchers.
The document summarizes the Global Initiative for Asthma (GINA) strategy for managing asthma. It provides:
1) An overview of the GINA program, which takes a practical, evidence-based approach to managing asthma globally.
2) Details on key changes in the 2016 GINA strategy, including new treatment recommendations and a focus on low-resource settings.
3) Information on defining and diagnosing asthma, emphasizing the use of symptom history and tests to confirm variable airflow limitation.
This document provides guidelines for the global management and prevention of asthma. It was revised in 2014 by the Global Initiative for Asthma (GINA) organization. GINA aims to disseminate information about asthma care worldwide and provide an evidence-based framework to improve asthma management. The guidelines are informed by international experts and focus on control-based management of asthma with medications and self-management education.
This document discusses tachypnoea (rapid breathing) in well babies. It begins by covering the physiology of breathing in infants, noting that respiratory rate typically decreases over the first year of life. It defines tachypnoea in infants as a respiratory rate over 60 breaths per minute. The document emphasizes that accurately measuring respiratory rate can be challenging, and recommends using a stethoscope and taking the rate over a full minute while recording the baby's state. It also discusses periodic breathing patterns seen in infants.
This document provides a summary of the Global Initiative for Asthma's Pocket Guide for Asthma Management and Prevention. It discusses key points about asthma including:
- Asthma can be effectively treated and patients can achieve good control by avoiding symptoms, needing little reliever medication, and avoiding serious flare-ups.
- Factors like viral infections, allergens, tobacco smoke and exercise can trigger asthma symptoms, especially when asthma is uncontrolled.
- Asthma flare-ups can be fatal but are more common when asthma is uncontrolled. All patients should have an asthma action plan.
- A stepwise treatment approach customized for each patient uses medications effectively to reduce symptoms and risk of flare-ups. Regular controller treatment with
This document provides guidelines from the Global Initiative for Asthma (GINA) and the British Thoracic Society on the management of asthma. It discusses the diagnosis and classification of asthma, the components of asthma care including developing a treatment plan, identifying and reducing risk factors, assessing control and monitoring the condition. It outlines a stepwise approach to pharmacological treatment based on disease severity and control. Controller medications include inhaled corticosteroids, long-acting beta agonists, leukotriene modifiers and oral corticosteroids. Reliever medications like short-acting beta agonists are used for acute symptoms. The guidelines provide guidance on monitoring control and adjusting treatment accordingly.
This document summarizes the proceedings of the Small Airways Working Group Meeting held on September 9th, 2017 in Milan. It includes the agenda, list of attendees, and progress updates on several studies. Multiple studies comparing the effectiveness of extra-fine particle inhaled corticosteroids to fine particle ICS have been published or are underway. Preliminary results suggest extra-fine ICS may achieve better asthma control at lower doses and with fewer side effects like pneumonia. The group discussed potential future studies on flexible dosing strategies, metabolic effects of high dose ICS, and the impact of particle size in patients with obesity or GERD. Priority research areas and ongoing protocols were reviewed for continued relevance and feasibility.
The document discusses the use of inhalational devices in asthma care. It describes various aerosol delivery technologies used including metered-dose inhalers, dry powder inhalers, nebulizers, and spacer devices. It emphasizes that the goal of asthma therapy is optimal drug delivery to the lower airways while minimizing deposition in the upper airways. The document provides recommendations for inhaler use and techniques to optimize treatment. It also discusses challenges with various devices and potential solutions through patient education.
Format 2016: how to get asthma control: from PubMed to the tricks of the trade.Envicon Medical Srl
This document discusses strategies for achieving asthma control. It begins by establishing the importance of a partnership between healthcare providers and patients. Effective self-regulation is key, which involves patients observing their condition, making judgments, and reacting appropriately. Motivational interviewing can help patients progress through stages of change. Active listening from providers helps address patients' cognitive and emotional needs. Both verbal and nonverbal communication impact the relationship and treatment outcomes. Involving children in their care can improve satisfaction and adherence.
This document provides recommendations from the British guideline on the management of asthma. It recommends that the initial assessment of asthma in both children and adults should focus on taking a thorough clinical history and considering alternative diagnoses. For those with a high probability of asthma, treatment should be started, while further testing is reserved for poor responders. For intermediate probability cases, tests like lung function and a treatment trial can help determine if a diagnosis of asthma is appropriate. Self-management education and written asthma action plans are recommended to improve health outcomes.
This document presents a consensus on the diagnosis, management, and treatment of severe uncontrolled asthma. It defines severe asthma as requiring high doses of inhaled corticosteroids (ICS), with or without oral corticosteroids (OCS), to achieve control of symptoms and prevent exacerbations. Control refers to the level of symptom reduction achieved with treatment, while severity is an intrinsic characteristic of the underlying disease. The document proposes diagnostic algorithms and definitions for severe asthma and its various levels of control. It also describes different phenotypes and potential treatments for severe uncontrolled asthma.
Acute severe asthma exacerbations in children younger than 12 yearsDr. Ali Abdelrafie
- Childhood asthma is the most common chronic disease in children, affecting 5-10% worldwide and resulting in around 500,000 hospitalizations annually. While it cannot be cured, symptoms can be controlled with treatment to prevent lung damage.
- Status asthmaticus refers to an acute severe asthma exacerbation that does not improve with standard emergency department treatment and may progress to respiratory failure without aggressive intervention. It is characterized by severe airflow obstruction from airway inflammation, mucus production, and bronchospasm.
- Children presenting with acute severe asthma who do not improve with initial emergency department treatment should be admitted to the pediatric intensive care unit.
Child Health Working Group and Small Airways Study Group Joint MeetingZoe Mitchell
This document provides an agenda and background information for a meeting of the Small Airways & Child Health Working Group. The agenda includes discussions on ongoing publications regarding chest nomenclature and a systematic review on ICS particle size. Presentations will cover pre-school asthma wheeze, new ideas for the group focusing on implications of ICS particle size on GERD and ACOS, and an oscillometry study overview. Background information is provided on the chest commentary and systematic review, including results showing extra-fine ICS have higher odds of asthma control and lower exacerbation rates than fine particle ICS. A proposed study on pre-school asthma will compare outcomes of EF ICS to NEF ICS, LTRA,
This document summarizes some of the key changes in the 2017 versions of GINA (Global Initiative for Asthma) and GOLD (Global Strategy for Diagnosis, Management and Prevention of COPD). It discusses updates to the definitions of asthma and its diagnosis. The stepwise approach to asthma management has been updated, including adding sublingual immunotherapy as an optional add-on treatment for some adult patients. Other changes include guidance on stepping down treatment and side effects of oral corticosteroids.
Severe Asthma/Biomarkers Working Group ERS 2017Kathryn Brown
The document summarizes a meeting of the Severe Asthma/Biomarkers Joint Working Group. It includes an agenda for presentations on recent and ongoing projects related to using biomarkers like FeNO and blood eosinophils to predict outcomes in severe asthma. Presentations covered recent publications on these topics, updates on registry initiatives like ISAR and available data sources like OPCRD, and ideas for new projects. Attendees also discussed previous ideas around further evaluating biomarkers as predictors of treatment response and clinical outcomes.
The document summarizes key changes and recommendations from the 2015 Global Initiative for Asthma (GINA) update, including:
- Add-on tiotropium by soft-mist inhaler is a new treatment option for Steps 4 and 5 in patients ≥18 years with exacerbation history.
- Management of asthma in pregnancy includes monitoring for infections and using usual controllers during labor/delivery.
- Dry powder inhalers can deliver SABA in mild-moderate exacerbations but not for severe acute asthma.
- For life-threatening asthma in primary care, give SABA, ipratropium, systemic corticosteroids, and oxygen while arranging transfer.
This document provides an overview of the Global Initiative for Asthma (GINA) 2017 update. It outlines GINA's structure, objectives, and resources. Key points include:
- GINA aims to provide global asthma strategy recommendations for diagnosis, management, and prevention.
- It has a board of directors, science committee, and assembly of participating countries.
- Resources include the full GINA strategy report, pocket guides, and dissemination tools available on their website.
- The 2017 update focuses on areas like the asthma-COPD overlap, lung function assessments, FeNO measurements, and immunotherapy.
1) The study compared the efficacy of fluticasone propionate alone or in combination with salmeterol in achieving asthma control as defined by guidelines over 1 year in 3,421 patients with uncontrolled asthma.
2) Treatment was stepped up until total control was achieved or the maximum dose was reached, and significantly more patients achieved total and well-controlled asthma with salmeterol/fluticasone than with fluticasone alone.
3) The study confirms that guideline-defined asthma control can be achieved in the majority of patients through aggressive dose titration of controller medications.
This slide set provides an overview of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for chronic obstructive pulmonary disease (COPD). It defines COPD as a common lung disease characterized by airflow limitation caused by exposure to noxious particles or gases. The slide set outlines the GOLD board of directors and science committee, lists national leaders, and describes the objectives, evidence levels, and chapters covered in the 2017 GOLD report on defining, diagnosing, preventing, and managing COPD.
This document summarizes a meeting of the Asthma-COPD Overlap Working Group. The group discussed current and future projects on defining and studying Asthma-COPD Overlap (ACO). Their current project examines how ACO prevalence varies depending on the population definition used within a UK database. Future projects proposed examining ACO definitions across other databases and comparing outcomes for patients with ACO versus COPD. The group prioritized repeating their analyses in other databases as Phase 1 and studying patient outcomes as Phase 2. They discussed logistics of sharing data and analysis scripts between researchers.
The document summarizes the Global Initiative for Asthma (GINA) strategy for managing asthma. It provides:
1) An overview of the GINA program, which takes a practical, evidence-based approach to managing asthma globally.
2) Details on key changes in the 2016 GINA strategy, including new treatment recommendations and a focus on low-resource settings.
3) Information on defining and diagnosing asthma, emphasizing the use of symptom history and tests to confirm variable airflow limitation.
This document provides guidelines for the global management and prevention of asthma. It was revised in 2014 by the Global Initiative for Asthma (GINA) organization. GINA aims to disseminate information about asthma care worldwide and provide an evidence-based framework to improve asthma management. The guidelines are informed by international experts and focus on control-based management of asthma with medications and self-management education.
This document discusses tachypnoea (rapid breathing) in well babies. It begins by covering the physiology of breathing in infants, noting that respiratory rate typically decreases over the first year of life. It defines tachypnoea in infants as a respiratory rate over 60 breaths per minute. The document emphasizes that accurately measuring respiratory rate can be challenging, and recommends using a stethoscope and taking the rate over a full minute while recording the baby's state. It also discusses periodic breathing patterns seen in infants.
This document provides a summary of the Global Initiative for Asthma's Pocket Guide for Asthma Management and Prevention. It discusses key points about asthma including:
- Asthma can be effectively treated and patients can achieve good control by avoiding symptoms, needing little reliever medication, and avoiding serious flare-ups.
- Factors like viral infections, allergens, tobacco smoke and exercise can trigger asthma symptoms, especially when asthma is uncontrolled.
- Asthma flare-ups can be fatal but are more common when asthma is uncontrolled. All patients should have an asthma action plan.
- A stepwise treatment approach customized for each patient uses medications effectively to reduce symptoms and risk of flare-ups. Regular controller treatment with
This document provides guidelines from the Global Initiative for Asthma (GINA) and the British Thoracic Society on the management of asthma. It discusses the diagnosis and classification of asthma, the components of asthma care including developing a treatment plan, identifying and reducing risk factors, assessing control and monitoring the condition. It outlines a stepwise approach to pharmacological treatment based on disease severity and control. Controller medications include inhaled corticosteroids, long-acting beta agonists, leukotriene modifiers and oral corticosteroids. Reliever medications like short-acting beta agonists are used for acute symptoms. The guidelines provide guidance on monitoring control and adjusting treatment accordingly.
This document summarizes the proceedings of the Small Airways Working Group Meeting held on September 9th, 2017 in Milan. It includes the agenda, list of attendees, and progress updates on several studies. Multiple studies comparing the effectiveness of extra-fine particle inhaled corticosteroids to fine particle ICS have been published or are underway. Preliminary results suggest extra-fine ICS may achieve better asthma control at lower doses and with fewer side effects like pneumonia. The group discussed potential future studies on flexible dosing strategies, metabolic effects of high dose ICS, and the impact of particle size in patients with obesity or GERD. Priority research areas and ongoing protocols were reviewed for continued relevance and feasibility.
The document discusses the use of inhalational devices in asthma care. It describes various aerosol delivery technologies used including metered-dose inhalers, dry powder inhalers, nebulizers, and spacer devices. It emphasizes that the goal of asthma therapy is optimal drug delivery to the lower airways while minimizing deposition in the upper airways. The document provides recommendations for inhaler use and techniques to optimize treatment. It also discusses challenges with various devices and potential solutions through patient education.
Format 2016: how to get asthma control: from PubMed to the tricks of the trade.Envicon Medical Srl
This document discusses strategies for achieving asthma control. It begins by establishing the importance of a partnership between healthcare providers and patients. Effective self-regulation is key, which involves patients observing their condition, making judgments, and reacting appropriately. Motivational interviewing can help patients progress through stages of change. Active listening from providers helps address patients' cognitive and emotional needs. Both verbal and nonverbal communication impact the relationship and treatment outcomes. Involving children in their care can improve satisfaction and adherence.
This document provides recommendations from the British guideline on the management of asthma. It recommends that the initial assessment of asthma in both children and adults should focus on taking a thorough clinical history and considering alternative diagnoses. For those with a high probability of asthma, treatment should be started, while further testing is reserved for poor responders. For intermediate probability cases, tests like lung function and a treatment trial can help determine if a diagnosis of asthma is appropriate. Self-management education and written asthma action plans are recommended to improve health outcomes.
This document presents a consensus on the diagnosis, management, and treatment of severe uncontrolled asthma. It defines severe asthma as requiring high doses of inhaled corticosteroids (ICS), with or without oral corticosteroids (OCS), to achieve control of symptoms and prevent exacerbations. Control refers to the level of symptom reduction achieved with treatment, while severity is an intrinsic characteristic of the underlying disease. The document proposes diagnostic algorithms and definitions for severe asthma and its various levels of control. It also describes different phenotypes and potential treatments for severe uncontrolled asthma.
Acute severe asthma exacerbations in children younger than 12 yearsDr. Ali Abdelrafie
- Childhood asthma is the most common chronic disease in children, affecting 5-10% worldwide and resulting in around 500,000 hospitalizations annually. While it cannot be cured, symptoms can be controlled with treatment to prevent lung damage.
- Status asthmaticus refers to an acute severe asthma exacerbation that does not improve with standard emergency department treatment and may progress to respiratory failure without aggressive intervention. It is characterized by severe airflow obstruction from airway inflammation, mucus production, and bronchospasm.
- Children presenting with acute severe asthma who do not improve with initial emergency department treatment should be admitted to the pediatric intensive care unit.
Child Health Working Group and Small Airways Study Group Joint MeetingZoe Mitchell
This document provides an agenda and background information for a meeting of the Small Airways & Child Health Working Group. The agenda includes discussions on ongoing publications regarding chest nomenclature and a systematic review on ICS particle size. Presentations will cover pre-school asthma wheeze, new ideas for the group focusing on implications of ICS particle size on GERD and ACOS, and an oscillometry study overview. Background information is provided on the chest commentary and systematic review, including results showing extra-fine ICS have higher odds of asthma control and lower exacerbation rates than fine particle ICS. A proposed study on pre-school asthma will compare outcomes of EF ICS to NEF ICS, LTRA,
This document summarizes some of the key changes in the 2017 versions of GINA (Global Initiative for Asthma) and GOLD (Global Strategy for Diagnosis, Management and Prevention of COPD). It discusses updates to the definitions of asthma and its diagnosis. The stepwise approach to asthma management has been updated, including adding sublingual immunotherapy as an optional add-on treatment for some adult patients. Other changes include guidance on stepping down treatment and side effects of oral corticosteroids.
Severe Asthma/Biomarkers Working Group ERS 2017Kathryn Brown
The document summarizes a meeting of the Severe Asthma/Biomarkers Joint Working Group. It includes an agenda for presentations on recent and ongoing projects related to using biomarkers like FeNO and blood eosinophils to predict outcomes in severe asthma. Presentations covered recent publications on these topics, updates on registry initiatives like ISAR and available data sources like OPCRD, and ideas for new projects. Attendees also discussed previous ideas around further evaluating biomarkers as predictors of treatment response and clinical outcomes.
The document summarizes key changes and recommendations from the 2015 Global Initiative for Asthma (GINA) update, including:
- Add-on tiotropium by soft-mist inhaler is a new treatment option for Steps 4 and 5 in patients ≥18 years with exacerbation history.
- Management of asthma in pregnancy includes monitoring for infections and using usual controllers during labor/delivery.
- Dry powder inhalers can deliver SABA in mild-moderate exacerbations but not for severe acute asthma.
- For life-threatening asthma in primary care, give SABA, ipratropium, systemic corticosteroids, and oxygen while arranging transfer.
OECD_Treatment of Multilateral Climate Related Flows and Consolidated Review ...AnnaDrutschinin
The document summarizes discussions from a meeting of experts on tracking climate finance provided through multilateral development banks and other organizations. Key points discussed include:
1) Several major multilateral development banks have not yet started reporting climate finance data to the OECD, complicating efforts to track total climate finance amounts.
2) A methodology was proposed to calculate coefficients for the share of various organizations' funding going to climate activities, to estimate members' imputed multilateral climate contributions.
3) A review of additional "green" funds identified over 100 that may provide climate-related finance. Priorities were established for improving tracking of contributions to top funds based on importance and availability of data.
El documento proporciona instrucciones para instalar Turbo C++ en 5 pasos: 1) descomprimir y abrir la carpeta de Turbo C++, 2) ejecutar Setup.exe, 3) seguir las instrucciones de instalación, 4) crear un acceso directo, y 5) copiar la carpeta tc al emulador. Luego explica cómo crear y compilar código simple en Turbo C++ para copiar y eliminar archivos.
El documento describe los activos intangibles, incluyendo sus características como no ser corpóreos y tener una vida útil mayor a un año, así como detalles sobre diferentes tipos como patentes, marcas y gastos de desarrollo. Explica también su reconocimiento contable, valuación inicial y final, y depreciación.
This document provides a summary of asthma management and prevention guidelines from the Global Initiative for Asthma (GINA). It discusses diagnosing asthma based on symptoms and lung function tests. It classifies asthma control into controlled, partly controlled, and uncontrolled. It outlines four components of asthma care: developing a patient-doctor partnership through education and action plans; identifying and reducing risk factors; assessing, treating, and monitoring asthma; and managing exacerbations. It provides figures to aid in diagnosis, classification, treatment approach, and monitoring based on control level. The goal is to help physicians and nurses effectively diagnose and manage asthma to achieve long-term control for patients.
This document provides a pocket guide for asthma management and prevention. It summarizes key information about asthma including that it is a common chronic disease affecting 300 million worldwide. Asthma causes symptoms like wheezing and can be effectively treated to achieve good control for most patients. The guide outlines diagnosing asthma based on symptoms and lung function tests, classifying control, the four components of asthma care, and special considerations for management.
This document provides guidelines for the global management and prevention of asthma. It summarizes the burden of asthma, factors that influence asthma development and expression, mechanisms of asthma including airway inflammation and pathophysiology. It also outlines recommendations for diagnosing and classifying asthma, as well as treating asthma with medications. The treatment section provides guidance on controller and reliever medications for both adults and children. Additionally, it describes components of asthma management and prevention, including developing patient-doctor partnerships, identifying and reducing risk factors, assessing and monitoring asthma control, managing exacerbations, and special considerations.
This document provides a 3-sentence summary of the given document:
The document is the 2012 updated Global Strategy for Asthma Management and Prevention report published by the Global Initiative for Asthma (GINA). It outlines recommendations for diagnosing and classifying asthma, as well as treating asthma with medications and managing asthma prevention. The report was updated by the GINA Board of Directors and Science Committee, which include asthma experts from around the world.
This document provides a 3-sentence summary of the Global Strategy for Asthma Management and Prevention 2012 report:
The report is authored by an international board and committee and provides updated clinical recommendations for diagnosing and managing asthma based on assessing, treating, and maintaining asthma control. It describes factors that influence asthma such as genetics, environment, and lifestyle, and covers approaches to developing partnerships with patients, identifying and reducing risk factors, treating asthma with different medication types and delivery methods, and managing exacerbations. The report is intended to help health care professionals provide effective and individualized care for people with asthma globally.
1. The document discusses guidelines from the Global Initiative for Asthma (GINA) for diagnosing and managing asthma.
2. Asthma is defined as a chronic inflammatory disease characterized by variable respiratory symptoms and airflow limitation. It affects 300 million people worldwide.
3. GINA recommends a stepwise approach to asthma treatment based on symptom control and exacerbation risk. Treatment includes inhaled corticosteroids, long-acting beta-agonists, and leukotriene modifiers. The goal is to control symptoms and reduce future risk.
The document provides guidelines for the global strategy for asthma management and prevention as updated in 2022. It discusses that asthma is a serious global health problem affecting 300 million individuals worldwide. The guidelines provide a comprehensive approach to asthma management that can be adapted locally. It defines asthma as having respiratory symptoms such as wheezing and shortness of breath that vary over time in intensity, as well as variable expiratory airflow limitation. The diagnosis of asthma involves assessing symptoms, triggers, and lung function testing with reversibility. Treatment should be customized for each patient based on symptom control, risk factors, and medication effectiveness, safety and cost.
bronchialasthma in children treatment.pptxssuser90ffff
Bronchial asthma in children is a chronic inflammatory disease of the airways characterized by episodic and/or chronic airway obstruction symptoms that are at least partially reversible. It has both environmental and genetic risk factors and most cases onset before age 6. There are three main types - early childhood viral-induced wheezing, allergy-induced chronic asthma, and obesity-associated asthma in females. Treatment involves assessment, education, trigger avoidance, and medications to reduce inflammation and bronchoconstriction including inhaled corticosteroids, bronchodilators, and leukotriene modifiers.
Asthma is a chronic lung disease characterized by inflammation and narrowing of the airways. It commonly manifests as wheezing, chest tightness, coughing, and shortness of breath. While its exact causes are unknown, asthma is thought to involve both environmental and genetic factors. It affects around 13% of children and can be classified as either early childhood transient wheezing or chronic asthma associated with allergies. The main types of childhood asthma involve recurrent wheezing triggered by viral infections or chronic allergy-associated asthma. Management involves assessment, education, controlling triggers, and medications to reduce inflammation and bronchospasm.
This document provides an overview of asthma, including its diagnosis, treatment, and management. It discusses:
1) Asthma is a chronic inflammatory disease of the airways that causes symptoms like wheezing and shortness of breath. It affects 300 million people worldwide.
2) Diagnosis involves assessing symptoms, lung function tests, and ruling out other conditions. Treatment follows a stepwise approach based on disease severity and control.
3) Treatment includes controller medications like inhaled corticosteroids to control inflammation as well as quick-relief medications for symptoms. The goal is long-term control with minimal risks or side effects.
PALLIATIVE CARE (GROUP2) BME3 2023.pptxssuser504dda
Cough is an important reflex to clear the lungs. Chronic cough lasts more than 8 weeks and is common in advanced cancers, COPD, and other chronic diseases. Chronic cough profoundly impacts quality of life by interfering with sleep, eating, and social activities. A comprehensive assessment of cough considers cause, triggers, severity, and impact on quality of life to guide treatment, which may include non-pharmacological interventions, symptomatic therapies, and treating reversible underlying causes.
- Asthma is a chronic inflammatory disease of the airways characterized by airway hyperresponsiveness and reversible bronchospasm.
- It most commonly begins in childhood, with over 77% of cases presenting before 5 years of age. Diagnosis can be challenging in young children due to their inability to perform pulmonary function tests.
- Treatment involves inhalation of corticosteroids and bronchodilators. Short courses of oral corticosteroids are used for acute exacerbations. Patient education is important for proper inhaler technique and trigger avoidance.
Gina - global initiative against asthmaadithya2115
The document describes the Global Initiative for Asthma (GINA) program, which aims to increase awareness of asthma as a global health problem and provide evidence-based guidelines for diagnosis and management. GINA develops global strategy documents and provides resources to help implement asthma guidelines. The strategy follows a stepwise treatment approach based on asthma control levels to achieve treatment goals of control and prevention of exacerbations using inhaled corticosteroids and other controllers.
Asthma is a chronic inflammatory disease of the airways characterized by episodic obstruction, bronchial hyperresponsiveness, and reversibility of airflow obstruction. It affects 9.6 million US children and is more common in boys, children in poor families, and those with onset before age 6. Treatment involves assessment, education, trigger identification, and medications to reduce inflammation and bronchoconstriction. The goal is optimal asthma control through a stepwise treatment approach based on severity. Prognosis depends on severity, with milder cases often improving over time. Prevention focuses on avoiding tobacco smoke, prolonged breastfeeding, active lifestyles, and immunizations.
This document provides a summary of the Global Initiative for Asthma's (GINA) pocket guide for asthma management and prevention. It outlines key information about asthma including how to diagnose it, assess control, manage treatment, and handle exacerbations. The goal of the GINA strategy is to help health professionals effectively treat asthma so patients can lead active lives with well-controlled symptoms. Regular treatment with inhaled corticosteroids is emphasized as the most effective way to reduce exacerbations and achieve good asthma control.
This document provides a summary of the Global Initiative for Asthma's (GINA) Pocket Guide for Asthma Management and Prevention. It is intended to help health professionals manage asthma. The guide discusses diagnosing and assessing asthma, developing a treatment plan, managing exacerbations, and special populations. The key aspects are confirming the diagnosis of asthma based on symptoms and lung function tests, determining a patient's level of control, adjusting treatment through a stepwise approach, ensuring proper inhaler technique and adherence, and creating a written asthma action plan for self-management. The goal of treatment is achieving good symptom control and minimizing future risk through the use of controller medications such as inhaled corticosteroids.
This document provides a summary of the Global Initiative for Asthma (GINA) pocket guide for asthma management and prevention. It outlines criteria for diagnosing asthma, assessing asthma control, treating asthma, and managing exacerbations. The key aspects are:
- Asthma is diagnosed based on symptoms of variable airflow limitation and evidence of variable expiratory airflow. Spirometry is used to assess lung function and reversibility.
- Asthma control is assessed based on recent symptoms and future risk factors. Control includes both symptom control and risk of exacerbations. Treatment is adjusted based on level of control.
- Treatment follows a stepwise approach starting with education and inhaler technique, then usually inhaled corticost
Asthma is a common chronic lung disease that affects millions of Americans. It can cause symptoms like wheezing, coughing, chest tightness and shortness of breath. While deaths from asthma have decreased with better treatment, it remains a serious disease that has high costs due to hospitalizations and emergency room visits. The key to managing asthma is to control inflammation and minimize triggers through patient education, an asthma action plan, and appropriate long-term controller medications.
ast ma bronchial vb .pptx bronchial asthmaSaurav Jangir
This document provides an overview of the Global Initiative for Asthma (GINA) 2015 update. It discusses the structure and goals of GINA, which aims to provide an evidence-based global strategy for asthma management and prevention. The document reviews key changes in the 2015 GINA update, including revisions to the definitions of asthma and asthma control. It also summarizes GINA's approach to assessing evidence and provides slides on the diagnosis and treatment of asthma.
แนวทางการจัดการความเสี่ยงที่ส่งผลต่อต้นทุนการจัดการสินค้าคงคลัง
ของร้านขายยา CDE ในจังหวัดขอนแก่น
The Approach of Risk Management that Affecting the
Inventory Management Cost of CDE Drugstore in Khonkaen Province
Best Practice in Communication
ราชวิทยาลัยกุมารแพทย์แห่งประเทศไทย สมาคมกุมารแพทย์แห่งประเทศไทย
บรรณาธิการ วินัดดา ปิยะศิลป์ วันดี นิงสานนท์
ISBN 978-616-91972-1-8
Saccharomyces boulardii in the prevention of antibiotic-associated diarrhoeaUtai Sukviwatsirikul
This systematic review and meta-analysis evaluated the effectiveness of Saccharomyces boulardii in preventing antibiotic-associated diarrhea in children and adults based on 21 randomized controlled trials involving 4780 participants. The administration of S. boulardii compared to placebo or no treatment reduced the risk of antibiotic-associated diarrhea from 18.7% to 8.5%. S. boulardii was effective in reducing the risk of antibiotic-associated diarrhea in both children and adults. It also reduced the risk of Clostridium difficile-associated diarrhea in children but not adults. Overall, the results confirm that S. boulardii is effective for preventing antibiotic-associated diarrhea in children and adults.
This document provides information on drugs used to treat acute diarrhea. It begins with definitions of diarrhea from WHO. It then discusses estimates of child mortality due to diarrhea in Thailand from 2010 to 2012. It presents data on the age distribution of diarrhea cases and hospital admissions. It lists common bacterial, viral, and parasitic pathogens that cause childhood diarrhea. It discusses the pathogenesis of acute diarrhea and describes fluid and electrolyte losses and consequences of dehydration and nutritional deficits. It provides details on fluid and electrolyte composition of diarrheal stool from different pathogens. It outlines the objectives of diarrhea treatment and causes of death. It then discusses use of oral rehydration therapy and solutions. It recommends probiotics, continued feeding, and zinc supplementation. It
Systematic review with meta-analysis: Saccharomyces boulardii in the preventi...Utai Sukviwatsirikul
This systematic review and meta-analysis evaluated the effectiveness of Saccharomyces boulardii in preventing antibiotic-associated diarrhea in children and adults based on 21 randomized controlled trials involving 4780 participants. The administration of S. boulardii compared to placebo or no treatment reduced the risk of antibiotic-associated diarrhea from 18.7% to 8.5%. S. boulardii was effective in reducing the risk of antibiotic-associated diarrhea in both children and adults. It also reduced the risk of Clostridium difficile-associated diarrhea in children. The quality of evidence was rated as moderate to low based on limitations in the design and reporting of the included studies. This meta-analysis confirms the effectiveness of
Saccharomyces boulardii in the prevention of antibiotic-associated diarrhoea ...Utai Sukviwatsirikul
Saccharomyces boulardii in the prevention of antibiotic-associated
diarrhoea in children: a randomized double-blind placebo-controlled
trial
M. KOTOWSKA, P. ALBRECHT & H. SZAJEWSKA
Department of Pediatric Gastroenterology and Nutrition, The Medical University of Warsaw, Warsaw, Poland
Accepted for publication 24 November 2004
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Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
One health condition that is becoming more common day by day is diabetes.
According to research conducted by the National Family Health Survey of India, diabetic cases show a projection which might increase to 10.4% by 2030.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
4. TABLE OF CONTENTS
PREFACE 3
WHAT IS KNOWN ABOUT ASTHMA? 5
DIAGNOSING 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 Maintain
Asthma 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 the
world and there is evidence that its prevalence has increased considerably
over the past 20 years, especially in children. The Global Initiative for
Asthma was created to increase awareness of asthma among health
professionals, public health authorities, and the general public, and to
improve prevention and management through a concerted worldwide
effort. The Initiative prepares scientific reports on asthma, encourages
dissemination and implementation of the recommendations, and promotes
international collaboration on asthma research.
The Global Initiative for Asthma offers a framework to achieve and maintain
asthma control for most patients that can be adapted to local health care
systems and resources. Educational tools, such as laminated cards, or
computer-based learning programs can be prepared that are tailored to
these systems and resources.
The Global Initiative for Asthma program publications include:
• Global Strategy for Asthma Management and Prevention (2011).
Scientific information and recommendations for asthma programs.
• Global Strategy for Asthma Management and Prevention
GINA Executive Summary. Eur Respir J 2008; 31: 1-36
• Pocket Guide for Asthma Management and Prevention for Adults
and 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 for
pediatricians and other health care professionals.
• What You and Your Family Can Do About Asthma. An information
booklet for patients and their families.
Publications are available from www.ginasthma.org.
This Pocket Guide has been developed from the Global Strategy for Asthma
Management and Prevention (Updated 2011). Technical discussions of
asthma, evidence levels, and specific citations from the scientific literature
are 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 and
Pharmaxis. The generous contributions of these companies assured that the
GINA Committees could meet together and publications could be printed
for wide distribution. However, the GINA Committee participants are solely
responsible for the statements and conclusions in the publications.
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WHAT IS KNOWN
ABOUT ASTHMA?
Unfortunately…asthma is one of the most common chronic diseases, with
an estimated 300 million individuals affected worldwide. Its prevalence is
increasing, especially among children.
Fortunately…asthma can be effectively treated and most patients can
achieve good control of their disease. When asthma is under control
patients 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, chest
tightness, and coughing, particularly at night or in the early morning.
• Asthma is a chronic inflammatory disorder of the airways. Chronically
inflamed airways are hyperresponsive; they become obstructed and
airflow is limited (by bronchoconstriction, mucus plugs, and increased
inflammation) when airways are exposed to various risk factors.
• Common risk factors for 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, chemical
irritants, and drugs (such as aspirin and beta blockers).
• A stepwise approach to pharmacologic treatment to achieve and
maintain control of asthma should take into account the safety of
treatment, potential for adverse effects, and the cost of treatment
required to achieve control.
• Asthma attacks (or exacerbations) are episodic, but airway inflammation
is chronically present.
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• For many patients, controller medication must be taken daily to prevent
symptoms, improve lung function, and prevent attacks. Reliever
medications 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 a
partnership between the person with asthma and his or her health care
team.
• Asthma is not a cause for shame. Olympic athletes, famous leaders,
other celebrities, and ordinary people live successful lives with asthma.
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DIAGNOSING ASTHMA
Asthma can often be diagnosed on the basis of a patient’s symptoms and
medical history (Figure 1).
Measurements of lung function provide an assessment of the severity,
repairability, and variability of airflow limitation, and help confirm the
diagnosis of asthma.
Spirometry is the preferred method of measuring airflow limitation and its
reversibility to establish a diagnosis of asthma.
• An increase in FEV1
of ≥ 12% and ≥ 200 ml after administration
of a bronchodilator indicates reversible airflow limitation consistent
withasthma.(However,mostasthmapatientswillnotexhibitreversibility
at 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 out—especially
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 both
diagnosis and monitoring of asthma.
• PEF measurements are ideally compared to the patient’s own previous
best measurements using his/her own peak flow meter.
• An improvement of 60 L/min (or≥ 20% of the pre-bronchodilator PEF)
after inhalation of a bronchodilator, or diurnal variation in PEF of
more than 20% (with twice-daily readings, more than 10%), suggests
a diagnosis of asthma.
Additional diagnostic tests:
• For patients with symptoms consistent with asthma, but normal lung
function, measurements of airway responsiveness to methacholine
and 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 diagnosis
of asthma, and can help to identify risk factors that cause asthma
symptoms 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 and
airway hyperresponsiveness are particularly important.
„„ Exercise-induced bronchoconstriction. Physical activity is an important
cause of asthma symptoms for most asthma patients, and for some
(including many children) it is the only cause. Exercise testing with an
8-minute running protocol can establish a firm diagnosis of asthma.
„„ Children 5 Years and Younger. Not all young children who wheeze
have asthma. In this age group, the diagnosis of asthma must be based
largely on clinical judgment, and should be periodically reviewed as
the child grows (see the GINA Pocket Guide for Asthma Management
and Prevention in Children 5 Years and Younger for further details).
„„ Asthma in the elderly. Diagnosis and treatment of asthma in the elderly
are complicated by several factors, including poor perception of
symptoms, acceptance of dyspnea as being “normal” for old age, and
reduced expectations of mobility and activity. Distinguishing asthma
from COPD is particularly difficult, and may require a trial of treatment.
„„ Occupational asthma. Asthma acquired in the workplace is a
diagnosis that is frequently missed. The diagnosis requires a defined
history of occupational exposure to sensitizing agents; an absence of
asthma symptoms before beginning employment; and a documented
relation¬ship between symptoms and the workplace (improvement in
symptoms away from work and worsening of symptoms upon returning
to work).
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CLASSIFICATION OF ASTHMA
BY LEVEL OF CONTROL
The goal of asthma care is to achieve and maintain control of the clinical
manifestations of the disease for prolonged periods. When asthma is
controlled, patients can prevent most attacks, avoid troublesome symptoms
day and night, and keep physically active.
The assessment of asthma control should include control of the clinical
manifestations and control of the expected future risk to the patient such
as exacerbations, accelerated decline in lung function, and side-effects of
treatment. In general, the achievement of good clinical control of asthma
leads to reduced risk of exacerbations.
Figure 2 describes 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
A. Assessment of current clinical control (preferably over 4 weeks)
Characteristics Controlled
(All of the following)
Partly Controlled
(Any measure presented)
Uncontrolled
Daytime symptoms None (twice or less/week) More than twice/week Three or more features of
partly controlled asthma*†
Limitation of activities None Any
Nocturnal
symptoms/awaking
None Any
Need for reliever/
rescue inhaler
None (twice or less/week) More than twice/week
Lung function (PEF or FEV1
)‡ Normal < 80% predicted or
personal best (if known)
B. Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side effects)
Features that are associated with increased risk of adverse events in the future include:
Poor clinical control, frequent exacerbations in past year*, ever admission to critical care for asthma, low FEV1
, exposure to
cigarette smoke, high dose medications
* 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
‡ Without administration of bronchodilator, lung function is not a reliable test for children 5 years and younger.
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FOUR COMPONENTS OF
ASTHMA CARE
Four interrelated components of therapy are required to achieve and maintain
control of asthma:
Component 1. Develop patient/doctor partnership
Component 2. Identify and reduce exposure to risk factors
Component 3. Assess, treat, and monitor asthma
Component 4. Manage asthma exacerbations
Component 1: Develop Patient/Doctor Partnership
The effective management of asthma requires the development of a partnership
between 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 can
learn 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 care
professionals and patients. Using a variety of methods—such as discussions
(with a physician, nurse, outreach worker, counselor, or educator),
demonstrations, written materials, group classes, video or audio tapes,
dramas, and patient support groups—helps reinforce educational messages.
Working together, you and your patient should prepare a written personal
asthma action plan that is medically appropriate and practical. A sample
asthma plan is shown in Figure 3.
Additional written asthma action plans can be found on several websites,
including:
www.asthma.org.uk
www.nhlbisupport.com/asthma/index.html
www.asthmanz.co.nz
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Figure 3. Example of Contents of a Written Asthma to Maintain Asthma Control
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
Walking 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 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. Use ______ mg of __________________________(oral glucocorticosteriod).
3. Seek medical help: Go to _______________________________
______________Address:________________________Phone:
__________________________
4. Continue to use your __________________________________[reliever
medication] until your are able to get medical help.
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Component 2: Identify and Reduce Exposure to Risk Factors
To improve control of asthma and reduce medication needs, patients should
take steps to avoid the risk factors that cause their asthma symptoms (Figure
4). However, many asthma patients react to multiple factors that are ubiquitous
in the environment, and avoiding some of these factors completely is nearly
impossible. Thus, medications to maintain asthma control have an important
role because patients are often less sensitive to these risk factors when their
asthma is under control.
Physical activity is a common cause of asthma symptoms but patients should not
avoid exercise. Symptoms can be prevented by taking a rapid-acting inhaled
β2
-agonist before strenuous exercise (a leukotriene modifier or cromone are
alternatives).
Patients with moderate to severe asthma should be advised to receive an
influenza vaccination every year, or at least when vaccination of the general
population is advised. Inactivated influenza vaccines are safe for adults and
children over age 3.
Avoidance measures that improve control of asthma and reduce medication needs:
• Tobacco smoke: Stayawayfromtobaccosmoke.Patientsandparentsshouldnotsmoke.
• Drugs, foods, and additives: Avoid if they are known to case symptoms.
• Occupational sensitizers: Reduce or, preferably, avoid exposure to these agents
Reasonable avoidance measures that can be recommended but have not been shown to have clinical benefit
• House dust mites: Wash bed linens and blankets weekly in hot water and dry in a hot
dryer or sun. Encase pillows and mattresses in air-tight covers. Replace carpets with hard
flooring, especially in sleeping rooms. (If possible, use vacuum cleaner with filters. Use
acaricides or tannic acid to kill mites--but make sure the patient is not at home when the
treatment occurs.
• Animals with fur: Use air filters. (Remove animals from the home, or at least from the
sleeping area. Wash the pet.)
• Cockroaches: Clean home thoroughly and often. Use pesticide spray--but make sure
the patient is not at home when spraying occurs.
• Outdoor pollens and mold: Close windows and doors and remain indoors when
pollen and mold counts are highest.
• Indoor mold: Reduce dampness in the home; clean any damp areas frequently
Figure 4. Strategies for Avoiding Common Allergens and Pollutants
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Component 3: Assess, Treat and Monitor Asthma
The goal of asthma treatment—to 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, and
uncontrolled asthma is provided in Figure 2.
Treating to Achieve Control
Each patient is assigned to one of five treatment “steps.” Figure 5 details the
treatments at each step for adults and children age 5 and over.
At each treatment step, reliever medication should be provided for quick
relief of symptoms as needed. (However, be aware of how much reliever
medication the patient is using—regular or increased use indicates that
asthma is not well controlled.)
At Steps 2 through 5, patients also require one or more regular controller
medications, which keep symptoms and attacks from starting. Inhaled
glucocorticosteroids (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 be
considered to have difficult-to-treat asthma. In these patients, a compromise
may need to be reached focusing on achieving the best level of control
feasible—with as little disruption of activities and as few daily symptoms as
possible—while 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 A and Appendix B) and reliever (Appendix
C) medications for asthma are available. The recommended treatments are
guidelines only. Local resources and individual patient circumstances should
determine the specific therapy prescribed for each patient.
Inhaled medications are preferred because they deliver drugs directly to the
airways where they are needed, resulting in potent therapeutic effects with
fewer systemic side effects. Inhaled medications for asthma are available
as pressurized metered-dose inhalers (pMDIs), breath-actuated MDIs, dry
powder inhalers (DPIs), and nebulizers. Spacer (or valved holding-chamber)
devices make inhalers easier to use and reduce systemic absorption and
side effects of inhaled glucocorticosteroids.
Teach patients (and parents) how to use inhaler devices. Different devices
need 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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Figure 5. Management Approach Based on Control Adults and Children Older Than 5 Years
Controller
options***
Treatment Steps
As needed rapid-
acting β2-agonist
As needed rapid-acting β2-agonist
Low-dose ICS plus
long-acting β2-agonist
Select one
Leukotriene
modifier**
Select one
Medium-or
high-dose ICS
Medium-or high-dose
ICS plus long-acting
β2-agonist
Low-dose ICS plus
leukotriene modifier
Low-dose ICS plus
sustained release
theophylline
To Step 3 treatment,
select one or more
To Step 4 treatment,
add either
Asthma education. Environmental control.
(If step-up treatment is being considered for poor symptom control, first check inhaler technique, check adherence, and confirm symptoms are due to asthma.)
Low-dose inhaled
ICS*
Oral glucocorticosteroid
(lowest dose)
Anti-IgE
treatment
Leukotriene
modifier
Sustained release
theophylline
Controlled Maintain and find lowest controlling step
Partly controlled Consider stepping up to gain control
Uncontrolled Step up until controlled
Exacerbation Treat as exacerbation
Treatment ActionLevel of Control
Reduce
Reduce Increase
Increase
2Step1Step 3Step 4Step 5Step
*ICS = inhaled glucocorticosteroids
**=Receptor antagonist or synthesis inhibitors
***=Recommneded treatment (shaded boxes) based on group mean data. Individual patient needs, preferences, and cirumstances
(including costs) should be considered.
Alternative reliever treatments include inhaled anticholinergics, short-acting oral β2-agonists, some long-acting β2
-agonists, and short-acting theophylline.
Regular dosing with short and long-acting β2-agonists is not advised unless accompanied by regular use of an inhaled glucocorticorsteriod.
For management of asthma in children 5 years and younger, refer to the Global Strategy for the Diagnosis and Management
of Asthma in Children 5 Years and Younger, available at http://www.ginasthma.org.
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Figure 6. Estimated Equipotent Daily Doses of Inhaled
Glucocorticosteroids for Adults and Children Older than 5 Years †
Drug Low Dose (µg)†
Medium Daily Dose
(µg)†
High Daily Dose (µg)†
Beclomethasone
dipropionate - CFC
200 - 500 > 500 - 1000 > 1000 - 2000
Beclomethasone
dipropionate - HFA
100 - 250 > 250 - 500 > 500 - 1000
Budesonide* 200 - 400 > 400 - 800 > 800 - 1600
Ciclesonide* 80 - 160 > 160 - 320 > 320 - 1280
Flunisolide 500 - 1000 > 1000 - 2000 >2000
Fluticasone propionate 100 - 250 > 250 - 500 >500 - 1000
Mometasone furoate* 200 >400 >800
Triamcinolone
acetonide
400 - 1000 >1000 - 2000 >2000
† Comparisons based on efficacy data.
‡ Patients considered for high daily doses except for short periods should be referred to a specialist for assessment to
consider alternative combinations of controllers. Maximum recommended doses are arbitrary but with prolonged use are
associated with increased risk of systemic side effects.
* Approved for once-daily dosing in mild patients.
Notes
• The most important determinant of appropriate dosing is the clinician's judgment of the patient's response
to therapy. The clinician must monitor the patient's response in terms of clinical control and adjust the dose
accordingly. Once control of asthma is achieved, the dose of medication should be carefully titrated to the
minimum dose required to maintain control, thus reducing the potential for adverse effects.
• Designation of low, medium, and high doses is provided from manufacturers' recommendations where possible.
Clear demonstration of dose response relationships is seldom provided or available. The principle is therefore to
establish the minimum effective controlling dose in each patient, as higher doses may not be more effective and
are likely to be associated with greater potential for adverse effects.
• As CFC preparations are taken from the market, medication inserts for HFA preparations should be carefully
reviewed by the clinician for the equivalent correct dosage.
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Monitoring to Maintain Control
Ongoing monitoring is essential to maintain control and establish the lowest
step and dose of treatment to minimize cost and maximize safety.
Typically, patients should be seen one to three months after the initial visit,
and every three months thereafter. After an exacerbation, follow-up should be
offered within two weeks to one month.
At each visit, ask the questions listed in Figure 7.
Adjusting medication:
• If asthma is not controlled on the current treatment regimen, step up
treatment. Generally, improvement should be seen within 1 month.
But first review the patient’s medication technique, compliance, and
avoidance of risk factors.
• If asthma is partly controlled, consider stepping up treatment, depending
on whether more effective options are available, safety and cost of
possible treatment options, and the patient’s satisfaction with the level
of control achieved.
• If control is maintained for at least 3 months, step down with a gradual,
stepwise reduction in treatment. The goal is to decrease treatment to the
least medication necessary to maintain control.
Monitoring is still necessary even after control is achieved, as asthma is a
variable disease; treatment has to be adjusted periodically in response to
loss of control as indicated by worsening symptoms or the development of an
exacerbation.
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Figure 7. Questions for Monitoring Asthma Care
IS THE ASTHMA MANAGEMENT PLAN MEETING EXPECTED GOALS
Ask the patient:
Has your asthma awakened you at night?
Have you needed more reliever medications than usual?
Have you needed any urgent medical are?
Has your peak flow been below your personal best?
Are you participating in your usual physical activities?
Action to consider:
Adjust medications and management plan as needed
(step up or down).
But first, compliance should be assessed.
IS THE PATIENT USING INHALERS, SPACER, OR PEAK FLOW METERS CORRECTLY?
Ask the patient:
Please show me how you take your medicine.
Action to consider:
Demonstrate correct technique.
Have patient demonstrate back.
IS THE PATIENT TAKING THE MEDICATIONS AND AVOIDING RISK
FACTORS ACCORDING TO THE ASTHMA MANAGEMENT PLAN?
Ask the patient, for example:
So that we may plan therapy, please tell me how
often you actually take the medicine.
What problems have you had following the
management plan or taking your medicine?
During the last month, have you ever stopped taking
your medicine because you were feeling better?
Action to consider:
Adjust plan to be more practical.
Problem solve with the patient to overcome barriers to
following the plan.
DOES THE PATIENT HAVE ANY CONCERNS?
Ask the Patient:
What concerns might you have about your asthma,
medicines, or management plan?
Action to consider:
Provide additional education to relieve concerns and
discussion to overcome barriers.
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Component 4: Manage Exacerbations
Exacerbations of asthma (asthma attacks) are episodes of a progressive increase
in shortness of breath, cough, wheezing, or chest tightness, or a combination
of these symptoms.
Do not underestimate the severity of an attack; severe asthma attacks may be life
threatening. Their treatment requires close supervision.
Patients at high risk of asthma-related death require closer attention and should
be encouraged to seek urgent care early in the course of their exacerbations.
These patients include those:
• With a history of near-fatal asthma requiring intubation and mechanical
ventilation
• Who have had a hospitalization or emergency visit for asthma within
the past year
• Who are currently using or have recently stopped using oral
glucocorticosteroids
• Who are not currently using inhaled glucocorticosteroids
• Who are over dependent on rapid-acting β2
-agnoists, especially those
who use more than one canister of salbutamol (or equivalent) monthly
• With a history of psychiatric disease or psychosocial problems,
including the use of sedatives
• With a history of noncompliance with an asthma medication plan
Patients should immediately seek medical care if:
• The attack is severe (Figure 8):
-- The patient is breathless at rest, is hunched forward, talks in words
rather than sentences (infant stops feeding), is agitated, drowsy, or
confused, has bradycardia, or has a respiratory rate greater than 30
per minute
-- Wheeze is loud or absent
-- -Pulse is greater than 120/min (greater than160/min for infants)
-- PEF is less than 60 percent of predicted or personal best, even after
initial treatment
-- The patient is exhausted
• The response to the initial bronchodilator treatment is not prompt and
sustained for at least 3 hours
• There is no improvement within 2 to 6 hours after oral glucocorticosteroid
treatment is started
• There is further deterioration
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Mild attacks, defined by a reduction in peak flow of less than 20%, nocturnal
awakening, and increased us of rapid-acting β2
-agonists, can usually be treated
at home if the patient is prepared and has a personal asthma management
plan that includes action steps.
Moderate attacks may require, and severe attacks usually require, care in a
clinic or hospital.
Asthma attacks require prompt treatment:
• Inhaled rapid-acting β2
-agonists in adequate does are essential.
(Begin with 2 to 4 puffs every 20 minutes for the first hour; then mild
exacerbations will require 2 to 4 puffs every 3 to 4 hours, and moderate
exacerbations 6 to 10 puffs every 1 to 2 hours.)
• Oral glucocorticosteroids (0.5 to 1 mg of prednisolone/kg or equivalent
during a 24-hour period) introduced early in the course of a moderate or
severe attack help to reverse the inflammation and speed recovery.
• Oxygen is given at health centers or hospitals if the patient is hyopxemic
(achieve O2
saturation of 95%)
• Combination β2
-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 high
doses of inhaled β2
-agonists. However, theophylline can be used if
inhaled β2
-agonists are not available. If the patient is already taking
theophylline on a daily basis, serum concentration should be measured
before adding short-acting theophylline.
• Patients with severe asthma exacerbations unresponsive to bronchodilators
and systemic glucocorticosteroids, 2 grams of magnesium sulphate IV has
been 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, also
assess oxygen saturation; consider arterial blood gas measurement in patients
with suspected hypoventilation, exhaustion, severe distress, or peak flow 30-50
percent predicted.
Follow up:
After the exacerbation is resolved, the factors that precipitated the exacerbation
should be identified and strategies for their future avoidance implemented, and
the patient’s medication plan reviewed.
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Figure 8. Severity of Asthma Exacerbations*
Parameter Mild Moderate Severe Respiratory
arrest imminent
Breathless Walking
Can lie down
Talking
Infant - softer, shorter cry;
difficulty feeding
Preferr sitting
At rest
Infant stops feeding
Hunched forward
Talks in Sentences Phrases Words
Alertness May be agitated Usually agitated Usually agitated Drowsy or confused
Respiratory rate Increased Increased Often > 30/min
Normal rates of breathing in awake children:
Age Normal rate
< 2 months <60/min
2 -12 months <50 /min
1- 5 years <40/min
6 - 8 years < 30/min
Accessory muscles
andsuprasternal
retractions
Usually not Usually Usually Paradoxical
thoraco-abdominal
movement
Wheeze Moderate, often only
and expiratory
Loud Usually loud Absence of wheeze
Pulse/min. <100 100 - 200 >120 Bradycardia
Guide to limits of normal pulse rate in children:
Infants 2 - 12 months - Normal rate< 160/min
Preschool 1 - 2 years - Normal rate <120/mi
School age 2 - 8 years - Normal rate < 110/min
Pulsus paradoxus Absent < 10 mm Hg May be present
10 - 25 mm Hg
Often present
> 25 mm Hg (adult)
20 - 40 mm Hg (childe)
Absence suggests
respiratory muscle
fatique
PEF after initial
bronchodilator
% predicted or
% personal best
Over 80% Approx. 60-80% < 60% predicted or
personal best
(< 100 L/min adults)
or response lasts < 2 hrs
PaO2
(on air)†
and/or
paCO2
†
Normal
Test not usually
necessary
< 45 mm Hg
> 60 mm Hg
< 45 mm Hg
< 60 mm Hg
Possible cyanosis
> 45 mm Hg;
Possible respiratory
failure (see text)
SaO2
% (on air)†
>95% 91 - 95% <90%
Hypercapnia (hyperventilation) develops more readily in young children than adults and adolescents
*Note: The presence of several parameters, but no necessarily all, indicates the general classification of the exacerbation.
†Note: Kilopascals are also used internationally, conversion would be appropriate in this regard.
<60/min
<50 /min
<40/min
< 30/min
< 2 months
2 -12 months
1- 5 years
6 - 8 years
Infants
Preschool
School age
2 - 12 months
1 - 2 years
2 - 8 years
- Normal rate< 160/min
- Normal rate<120/min
- Normal rate< 110/min
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SPECIAL CONSIDERATIONS
IN MANAGING ASTHMA
„„ Pregnancy During pregnancy the severity of asthma often changes, and patients
may require close follow-up and adjustment of medications. Pregnant patients
with asthma should be advised that the greater risk to their baby lies with poorly
controlled asthma, and the safety of most modern asthma treatments should be
stressed. Acute exacerbations should be treated aggressively to avoid fetal hypoxia.
„„ Obesity. Management of asthma in the obese should be the same as patients with
normal 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 respiratory
complications, particularly with thoracic and upper abdominal surgeries. Lung
function should be evaluated several days prior to surgery, and a brief course of
glucocorticosteroids prescribed if FEV1
is less than 80% of the patient’s personal
best.
„„ Rhinitis, Sinusitis, and Nasal Polyps. Rhinitis and asthma often coexist in the same
patient, and treatment of rhinitis may improve asthma symptoms. Both acute and
chronic sinusitis can worsen asthma, and should be treated. Nasal polyps are
associated with asthma and rhinitis, often with aspirin sensitivity and most frequently
in adult patients. They are normally quite responsive to topical glucocorticosteroids.
„„ Occupational asthma. Pharmacologic therapy for occupational asthma is identical
to therapy for other forms of asthma, but is not a substitute for adequate avoidance
of the relevant exposure. Consultation with a specialist in asthma management or
occupational medicine is advisable.
„„ Respiratory infections. Respiratory infections provoke wheezing and increased
asthma symptoms in many patients. Treatment of an infectious exacerbation follows
the same principles as treatment of other exacerbations.
„„ Gastroesophageal reflux. Gastroesophageal reflux is more common in patients
with asthma compared to the general population. However, treatment with proton
pump inhibitors, H2
antagonists or surgery fail to improve asthma control.
„„ Aspirin-induced asthma. Up to 28 percent of adults with asthma, but rarely
children, suffer from asthma exacerbations in response to aspirin and other
nonsteroidal anti-inflammatory drugs. The diagnosis can only be confirmed by
aspirin challenge, which must be conducted in a facility with cardiopulmonary
resuscitation capabilities. Complete avoidance of the drugs that cause symptoms is
the standard management.
„„ Anaphylaxis. Anaphylaxis is a potentially life-threatening condition that can both
mimic and complicate severe asthma. Prompt treatment is crucial and includes
oxygen, intramuscular epinephrine, injectable antihistamine, intravenous
hydrocortisone, and intravenous fluid.
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Appendix A: Glossary of Asthma Medications - Controllers
Name and Also Known As Usual Doses Side Effects Comments
Glucocorticosteroids
Adrenocorticoids
Corticosteroids
Glucocorticoids
Inhaled (ICS):
Beclomethasone
Budesonide Ciclesonide
Flunisolide
Fluticasone Mometasone
Triamcinolone
Tablets or syrups:
hydrocortisone
methylprednisolone
prednisolone
prednosone
Inhaled: Beginning dose
dependent on asthma control then
titrated down over 2-3 months
to lowest effect dose once control
is achieved.
Tablets or syrups: For daily
control use lowest effective dose
5-40 mg of prednisone equivalent
in a.m. or qod.
For acute attacks 40-60 mg daily
in 1 or 2 divided doses for adults
or 1-2 mg/kg daily in children.
Inhaled: High daily doses may
be associated with skin thinning
and bruises, and rarely adrenal
suppression. Local side effects are
hoarseness and oropharyngeal
candidiasis. Low to medium doses
have produced minorgrowth
delay or suppression(av. 1cm) in
children. Attainment of predicted
adult height does not appear to
be affected.
Tablets or syrups: Used long
term, may lead toosteoporosis,
hypertension,diabetes, cataracts,
adrenal suppression, growth
suppression,obesity, skin
thinning or muscle weakness
Consider coexistingconditions
that could be worsened by
oral glucocorticosteroids,
e.g. herpes virusinfections,
Varicella, tuberculosis,
hypertension,diabetes and
osteoporosis
Inhaled: Inhaled: Potential but
small risk of side effects is well
balanced by efficacy. Valved
holding-chambers with MDIs
and mouth washing with DPIs
after inhalation decrease oral
Candidiasis. Preparations note
quivalent on per puff or µg basis.
Tablets or syrup:
Long term use: alternate day a.m.
dosing produces less toxicity.
Short term: 3-10 day "bursts" are
effective for gaining prompt control
Sodium cromoglycate
cromolyn
cromones
MDI 2 mg or 5 mg 2-4
inhalations 3-4 times daily.
Nebulizer 20 mg 3-4 times daily.
Minimalsideeffects.Coughmay
occuruponinhalation.
May take 4-6 weeks to determine
maximum effects. Frequent daily
dosing required.
Nedocromil
cromones
MDI 2 mg/puff 2-4 inhalations
2-4 times daily.
Cough may occur upon inhalation Some patients unable to tolerate
the taste.
Long-acting β2
-agonists
beta-adrenergis
sympathomimetics
LABAs
Inhaled:
Formoterol (F)
Salmeterol (Sm)
Sustained-release Tablets:
Salbutamol (S)
Terbutaline (T)
Aminophylline
methylxanthine
xanthine
Inhaled:
DPI - F: 1 inhalation (12 µg) bid.
MDI - F: 2 puffs bid.
DPI-Sm: 1 inhalation (50 µg) bid.
MDI -Sm: 2 puffs bid.
Tablets:
S: 4 mg q 12h.
T: 10 mg q 12h.
Starting does 10 mg/kg/day with
usual 800 mg maximum in 1-2
divided doses.
Inhaled: Inhaled: fewer, and
less significant, side effects than
tablets. Have been associated
with an increased risk of severe
exacerbations and asthma deaths
when added to usual therapy.
Tablets: Tablets: may cause
tachycardia, anxiety, skeletal
muscle tremor, headache,
hypokalemia.
Nausea and vomiting are most
common. Serious effects occurring
at higher serum concentrations
include seizures, tachycardia,
andarrhythmias.
Inhaled: SalmeterolNOTto
beusedtotreatacuteattacks.
Shouldnotuseasmonotherapyfor
controllertherapy.Alwaysuseas
adjuncttoICStherapy.Formoterol
hasonsetsimilartosalbutamoland
hasbeenusedasneededforacute
symptoms.
Tablets: As effective as
sustained-release theophylline.
No data for use as adjunctive
therapy with inhaled
glucocorticosteroids.
Theophylline level monitoring is
often required. Absorptionand
metabolism may be affected by
many factors,including febrile illness.
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Appendix A: Glossary of Asthma Medications - Controllers (continued…)
Name and Also Known As Usual Doses Side Effects Comments
Antileukotrienes
Leukotrienemodifiers
Montelukast(M)
Pranlukast(P)
Zafirlukast(Z)
Zileuton(Zi)
Adults: M 10mg qhs
P 450 mg bid
Z 20 mg bid;
Zi 600 mg qid.
Children:M5mgqhs(6-14y)
M4mgqhs(2-5y)
Z10mgbid(7-11y).
Nospecificadverseeffectstodate
atrecommendeddoses. Elevation
ofliverenzymeswithZafirlukast
andZileutonandlimitedcase
reportsofreversiblehepatitusand
hperbilirubinemiawithZileutonand
hepaticfailurewithafirlukast
Antiliukotrienesaremosteffectivefor
patietnswithmildpersistantasthma.
Theyprovideadditivebenefitwhen
addtoICSsthoughnootaseffective
asinhaledlong-actingβ2
-agonists.
Immunomodulators
Omalizumab
Anti-IgE
Adults:Doseadministered
subcutaneouslyevery2-4weeks
dependentonweightandIgE
concentration
Painandbruisingatinjectionsite
(5-20%)andveryrarelyanaphylaxis
(0.1%)
Need to be stored under
refrigeration 2-8° C and
maximum of 150 mg
administered per injection site.
Appendix B: Combination Medications for Asthma
Formulation Inhaler Devices
Doses Available
(µg)1
ICS/LABA
Inhalations/day Therapeutic Use
Fluticasone
propionate/
salmeterol
DPI
100/501
250/50
500/50
1 inhalation x 2 Maintenance
Fluticasone
propionate/
salmeterol
pMDI
(Suspension)
50/251
125/25
250/25
2 inhalations x 2 Maintenance
Budesonide/
formoterol
DPI
80/4.52
160/4.5
320/9.0
1-2 inhalations x 2
Maintenance
and Relief
Budesonide/
formoterol
pMDI
(Suspension)
100/6
200/6
2 inhalations x 2 Maintenance
Beclomethasone/
formoterol
pMDI
(Solution)
100/63
1-2 inhalations x 2 Maintenance
Mometasone/
formoterol
pMDI
100/5
200/5
2 inhalations x 2 Maintenance
ICS = inhaled corticocosteriod; LABA = long-acting β2
-agonist; pDMI = pressurized metered dose inhaler; DPI = dy powder inhaler
New formulations will be reviewed for inclusion in the table as they are approved. Such medications may be brought to the attention of the GINA Science Committee.
1
Refers to metered dose. For additional information about dosages and products available in specific countries, please consult www.gsk.com to find a link to your country
website or contact your local company representatives for products approved for use in your country.
2
Refers to delivered dose. For additional information about dosages and products available in specific countries, please consult www.astrazeneca.com to find a link to
your country website or contact your local company representatives for products approved for use in your country.
Refers to metered dose. For additional information about dosages and products available in specific countries, please consult www.chiesigroup.com to find a link to your
country website or contact your local company representatives for products approved for use in your country.
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Appedix C: Glossary of Asthma Medications - Relievers
Name and Also Known As Usual Doses Side Effects Comments
Short-acting β2
-agonists
Adrenergics
β2
-stimulants
Sympathomimetics
Albuterol/salbutamol
Fenoterol
Levalbuterol
Metaproterenol
Pirbuterol
Terbutaline
Differences in potency
exist but all product sare
essentially comparable
on a per puff basis For
pre symptomatic use and
pretreatment before exercise
2 puffs MDI or 1 inhalation
DPI. For asthma attacks 4-8
puffs q2-4h, may administer
q20min x 3 with medical
supervision or the equivalent
of 5 mg salbutamolby
nebulizer.
Inhaled: tachycardia,
skeletal muscle
tremor, headache, and
irritability. At very high
dose hyperglycemia,
hypokalemia.
Systemic
administration as
Tablets or Syrup
increases the risk of
these side effects.
Drug of choice for acute
bronchospasm. Inhaled route
has faster onset and is more
effective than tablet or syrup.
Increasing use, lack of expected
effect, or use of > 1 canister
a month indicate poor asthma
control; adjust long-term
therapy accordingly. Use of ≥ 2
canisters per month is associated
with an increased risk of a
severe, life-threatening asthma
attack.
Anticholinergics
Ipratropium bromide (IB)
Oxitropium bromide
IB-MDI 4-6 puffs q6h or
q20 min in the emergency
department. Nebulizer
500 µg q20min x 3 then
q2-4hrs for adults and 250-
500 µg for children.
Minimal mouth
dryness or bad taste
in the mouth.
May provide additive effects to
β2
-agonst but has slower onset
of acation. Is an alternative
for patients with intolerance to
β2
-agonsts.
Short-acting theophylline
Aminophylline
7 mg/kg loading dose over
20 min followed by 0.4mg/
kg/hr continuous infusion.
Nausea, vomiting,
headache. At higher
serum concentrations:
seizures,
tachycardia,and
arrhythmias.
Theophylline level monitoring is
required. Obtain serum levels
12 and 24 hours into infusion.
Maintain between 10-15 µg/
mL.
Epinephrine/adrenaline
injection
1:1000 solution
(1mg/mL) .01mg/kg
up to 0.3-0.5 mg, can
give q20min x 3.
Similar, but more
significant effects
than selective β2
-
agonist. In addition:
hypertension, vomiting
in children and
hallucinations
In general, not recommended
fro treating asthma attacks
if selective β2
-agonsts are
available.
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