The document provides guidelines for asthma management and prevention, outlining the four components of asthma care: developing a patient-doctor partnership; identifying and reducing exposure to risk factors; assessing, treating, and monitoring asthma; and managing exacerbations. It includes information on diagnosing asthma, classifying asthma control, pharmacological treatment approaches, and special considerations for managing different patient groups.
This document discusses how to build self-service sites using SharePoint 2010. It covers using SharePoint 2010 for authentication, authorization, and integrating with line of business systems. Authentication can be done with forms-based authentication or claims-based authentication supporting a variety of user repositories. Authorization can use claims-based authentication with security trimming and content targeting. Integrations can be done through iframes, business connectivity services, or a custom service layer. Additional features discussed include social elements, content management, mobile support, and summarizes that SharePoint 2010 provides a unified platform for marketing and self-service functionality.
Fast for sharepoint internet and commerce scenariosshmulik-tal
The document provides an overview of FAST Enterprise Search capabilities including its linguistic capabilities like type ahead, spell check, finding similar documents and synonyms. It describes FAST's faceted search, architecture, and support for multiple languages. The summary highlights FAST's capabilities for customizing search experiences through features like keywords, faceted navigation, and recommendations.
Bret dudl a seasoned olympics fan reflects on the games presentationBret Dudl
Bret Dudl is a seasoned Olympics fan who has attended the last seven Olympic Games. On his blog, he reflected on the lure of the Olympics, highlighting the drama, novelty, patriotism, and variety of sports offered at the Games. He also noted the personal sacrifices athletes make in overcoming fears of failure, competition, success, and years of hard work to compete at the Olympics.
SharePoint 2010 can serve as a digital presence platform that provides business users tools to self-manage an organization's digital presence across websites, mobile sites, and social media without extensive IT resources. It allows for flexible and easy-to-use content management and e-commerce capabilities. A digital presence platform should allow for dynamic page building, content sharing across channels, integrated social media, a mobile web presence, and other features to empower organizations to win across the digital landscape.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
This document discusses how to build self-service sites using SharePoint 2010. It covers using SharePoint 2010 for authentication, authorization, and integrating with line of business systems. Authentication can be done with forms-based authentication or claims-based authentication supporting a variety of user repositories. Authorization can use claims-based authentication with security trimming and content targeting. Integrations can be done through iframes, business connectivity services, or a custom service layer. Additional features discussed include social elements, content management, mobile support, and summarizes that SharePoint 2010 provides a unified platform for marketing and self-service functionality.
Fast for sharepoint internet and commerce scenariosshmulik-tal
The document provides an overview of FAST Enterprise Search capabilities including its linguistic capabilities like type ahead, spell check, finding similar documents and synonyms. It describes FAST's faceted search, architecture, and support for multiple languages. The summary highlights FAST's capabilities for customizing search experiences through features like keywords, faceted navigation, and recommendations.
Bret dudl a seasoned olympics fan reflects on the games presentationBret Dudl
Bret Dudl is a seasoned Olympics fan who has attended the last seven Olympic Games. On his blog, he reflected on the lure of the Olympics, highlighting the drama, novelty, patriotism, and variety of sports offered at the Games. He also noted the personal sacrifices athletes make in overcoming fears of failure, competition, success, and years of hard work to compete at the Olympics.
SharePoint 2010 can serve as a digital presence platform that provides business users tools to self-manage an organization's digital presence across websites, mobile sites, and social media without extensive IT resources. It allows for flexible and easy-to-use content management and e-commerce capabilities. A digital presence platform should allow for dynamic page building, content sharing across channels, integrated social media, a mobile web presence, and other features to empower organizations to win across the digital landscape.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
El documento contiene las configuraciones técnicas de 15 fotografías tomadas por Cecilia Moreno Payró, incluyendo la velocidad ISO, el obturador, la apertura y la longitud focal utilizadas en cada una. Todas las fotografías compartieron la misma configuración técnica de velocidad ISO 400, obturador de 1/60, apertura f/22.0 y longitud focal de 55mm.
The five Olympic rings represent the five continents that competed in the first modern Olympics in 1912. The official Olympic motto is "Citius altius fortius", which translates to "faster, higher, stronger" and represents striving for physical excellence. During an annual ritual beginning in 1936, the Olympic flame is lit in Greece and relayed to the host city to pay homage to the ancient Olympic games.
Érdekel egy olyan üzleti program, amely nem a meggyőzésről, hanem a tájékoztatásról szól?
Érdekel egy olyan lehetőség, amely azonnali bevételt biztosít, és már az első héten elszámolás és jutalék kifizetés vár a számládon?
Érdekel egy olyan start program, ahol új vásárlóként és kezdő üzletépítőként többet fizet vissza neked a cég, mint amennyit befektetsz?
Ez a DXN Dynamic Start Program!
Kiknek ajánljuk ezt a dinamikus programot?
Elsősorban azoknak az új DXN regisztrálóknak, akik egy dinamikus startot és azonnali bevételt szeretnének maguknak.
A DXN marketing terve mellet ez egy plusz lehetőséget jelent azoknak, akik azonnali megoldást és eredményt keresnek anyagi problémájukra.
Akiknek nincs idejük kivárni azt, hogy elérjenek egy üzleti szintet, nincs idejük 1-2 évet várni. https://www.dxn2u.eu/pws/310013424
The document discusses responsive web design and mobile web development. It covers technologies like HTML5, CSS3, JavaScript and frameworks like jQuery for building responsive websites that work across different screen sizes and devices. It also talks about using CSS3 media queries and responsive layout techniques to dynamically adapt websites for various viewports and browsers including older versions of Internet Explorer.
Share point 2010 , better place study caseshmulik-tal
The document discusses using SharePoint 2010 as a digital platform for three applications: an Israeli marketing website, a global self-service application, and a mobile web application. The Israeli marketing site features an enhanced CMS, lead integration, and social media publishing. The global self-service application supports multi-tenancy, content sharing, authentication, and backend integrations. The mobile web application allows managing a mobile site from SharePoint across devices using responsive design.
The document discusses native widgets, telephone numbers versus other contact methods, and SSL security. It mentions Realcommerce CTO Nir Levy and topics including native widgets, telephone versus number, and SSL security for websites and apps.
Performance Metrics Driven CI/CD - Introduction to Continuous Innovation and ...Mike Villiger
Deck used for my talk at the 2016 Spring User Conference in Toronto. Deck was followed up by a walkthrough of a Jenkins workflow that deployed to Cloud Foundry based on jmeter test results
This document discusses various health products from DXN including Ganoderma RG, Ganocelium GL, Reishilium Powder, Cordyceps, Cordypine, Morinzhi, Spirulina, Lion's Mane, and Lingzhi Coffee. It describes the key ingredients and health benefits of each product, which include balancing pH, improving blood circulation, boosting immunity, increasing oxygen levels, and maintaining overall wellness and longevity. Proper dosages and consumption methods are also outlined.
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
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.
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.
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
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 guidance on diagnosing and managing asthma in children aged 5 years and younger. It discusses risk factors for developing asthma such as sensitization to aeroallergens. For diagnosis, it recommends considering symptoms, tests, and ruling out other conditions. Treatment involves education, assessing control, and stepwise use of inhaled corticosteroids and bronchodilators. It provides guidance on acute exacerbations and monitoring treatment response. The goal is achieving long-term control of asthma symptoms with safe and effective pharmacotherapy.
DIETARY AVOIDANCE DURING PREGNANCY AND/OR LACTATION
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.
This document provides a summary of the Global Initiative for Asthma's Pocket Guide for Asthma Management and Prevention. It includes information on diagnosing asthma, assessing asthma control, developing a treatment plan, managing exacerbations, and special populations. The summary is as follows:
Asthma is a chronic disease characterized by variable respiratory symptoms and airflow limitation that can be effectively treated. This document provides guidance for healthcare professionals on diagnosing asthma, assessing control, developing a stepwise treatment plan using inhaled corticosteroids and other controllers, managing exacerbations with action plans, and addressing special populations. The goal is to help patients achieve good symptom control and minimize future risk through a customized approach.
Pocket Guide for Asthma Management and Prevention (GINA 2017)Utai Sukviwatsirikul
This document provides a summary of the Global Initiative for Asthma's Pocket Guide for Asthma Management and Prevention. It discusses diagnosing and assessing asthma, managing asthma through a stepwise treatment approach, and treating asthma exacerbations. The summary focuses on the key points:
- Asthma is diagnosed based on a history of respiratory symptoms and evidence of variable expiratory airflow limitation. Special populations like smokers may have asthma-COPD overlap.
- Patients are assessed for asthma control using symptom frequency and lung function tests. Treatment is adjusted based on a stepwise approach to control symptoms and minimize future risk.
- Initial controller treatment involves low-dose inhaled corticosteroids with add-on treatment for uncontrolled
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.
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.
El documento contiene las configuraciones técnicas de 15 fotografías tomadas por Cecilia Moreno Payró, incluyendo la velocidad ISO, el obturador, la apertura y la longitud focal utilizadas en cada una. Todas las fotografías compartieron la misma configuración técnica de velocidad ISO 400, obturador de 1/60, apertura f/22.0 y longitud focal de 55mm.
The five Olympic rings represent the five continents that competed in the first modern Olympics in 1912. The official Olympic motto is "Citius altius fortius", which translates to "faster, higher, stronger" and represents striving for physical excellence. During an annual ritual beginning in 1936, the Olympic flame is lit in Greece and relayed to the host city to pay homage to the ancient Olympic games.
Érdekel egy olyan üzleti program, amely nem a meggyőzésről, hanem a tájékoztatásról szól?
Érdekel egy olyan lehetőség, amely azonnali bevételt biztosít, és már az első héten elszámolás és jutalék kifizetés vár a számládon?
Érdekel egy olyan start program, ahol új vásárlóként és kezdő üzletépítőként többet fizet vissza neked a cég, mint amennyit befektetsz?
Ez a DXN Dynamic Start Program!
Kiknek ajánljuk ezt a dinamikus programot?
Elsősorban azoknak az új DXN regisztrálóknak, akik egy dinamikus startot és azonnali bevételt szeretnének maguknak.
A DXN marketing terve mellet ez egy plusz lehetőséget jelent azoknak, akik azonnali megoldást és eredményt keresnek anyagi problémájukra.
Akiknek nincs idejük kivárni azt, hogy elérjenek egy üzleti szintet, nincs idejük 1-2 évet várni. https://www.dxn2u.eu/pws/310013424
The document discusses responsive web design and mobile web development. It covers technologies like HTML5, CSS3, JavaScript and frameworks like jQuery for building responsive websites that work across different screen sizes and devices. It also talks about using CSS3 media queries and responsive layout techniques to dynamically adapt websites for various viewports and browsers including older versions of Internet Explorer.
Share point 2010 , better place study caseshmulik-tal
The document discusses using SharePoint 2010 as a digital platform for three applications: an Israeli marketing website, a global self-service application, and a mobile web application. The Israeli marketing site features an enhanced CMS, lead integration, and social media publishing. The global self-service application supports multi-tenancy, content sharing, authentication, and backend integrations. The mobile web application allows managing a mobile site from SharePoint across devices using responsive design.
The document discusses native widgets, telephone numbers versus other contact methods, and SSL security. It mentions Realcommerce CTO Nir Levy and topics including native widgets, telephone versus number, and SSL security for websites and apps.
Performance Metrics Driven CI/CD - Introduction to Continuous Innovation and ...Mike Villiger
Deck used for my talk at the 2016 Spring User Conference in Toronto. Deck was followed up by a walkthrough of a Jenkins workflow that deployed to Cloud Foundry based on jmeter test results
This document discusses various health products from DXN including Ganoderma RG, Ganocelium GL, Reishilium Powder, Cordyceps, Cordypine, Morinzhi, Spirulina, Lion's Mane, and Lingzhi Coffee. It describes the key ingredients and health benefits of each product, which include balancing pH, improving blood circulation, boosting immunity, increasing oxygen levels, and maintaining overall wellness and longevity. Proper dosages and consumption methods are also outlined.
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
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.
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.
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
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 guidance on diagnosing and managing asthma in children aged 5 years and younger. It discusses risk factors for developing asthma such as sensitization to aeroallergens. For diagnosis, it recommends considering symptoms, tests, and ruling out other conditions. Treatment involves education, assessing control, and stepwise use of inhaled corticosteroids and bronchodilators. It provides guidance on acute exacerbations and monitoring treatment response. The goal is achieving long-term control of asthma symptoms with safe and effective pharmacotherapy.
DIETARY AVOIDANCE DURING PREGNANCY AND/OR LACTATION
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.
This document provides a summary of the Global Initiative for Asthma's Pocket Guide for Asthma Management and Prevention. It includes information on diagnosing asthma, assessing asthma control, developing a treatment plan, managing exacerbations, and special populations. The summary is as follows:
Asthma is a chronic disease characterized by variable respiratory symptoms and airflow limitation that can be effectively treated. This document provides guidance for healthcare professionals on diagnosing asthma, assessing control, developing a stepwise treatment plan using inhaled corticosteroids and other controllers, managing exacerbations with action plans, and addressing special populations. The goal is to help patients achieve good symptom control and minimize future risk through a customized approach.
Pocket Guide for Asthma Management and Prevention (GINA 2017)Utai Sukviwatsirikul
This document provides a summary of the Global Initiative for Asthma's Pocket Guide for Asthma Management and Prevention. It discusses diagnosing and assessing asthma, managing asthma through a stepwise treatment approach, and treating asthma exacerbations. The summary focuses on the key points:
- Asthma is diagnosed based on a history of respiratory symptoms and evidence of variable expiratory airflow limitation. Special populations like smokers may have asthma-COPD overlap.
- Patients are assessed for asthma control using symptom frequency and lung function tests. Treatment is adjusted based on a stepwise approach to control symptoms and minimize future risk.
- Initial controller treatment involves low-dose inhaled corticosteroids with add-on treatment for uncontrolled
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.
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 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.
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 introduces the challenges of chronic disease care and the need for integrated management. It notes that most people with chronic diseases do not receive appropriate care, with only about 1 in 10 treated successfully. This is due to inadequate management and lack of access. The document argues for integrated management of chronic diseases, as most people have multiple conditions or risk factors. It also calls for integrating chronic care within overall health services, as chronic diseases can be associated with other health issues. A holistic, patient-centered approach benefits all. The optimal solution is not just scaling up current systems but transforming them through strengthened primary care.
This document provides a user's manual for monitoring labor using a partograph. It describes the observations that should be charted on the partograph, including cervical dilation, fetal descent, uterine contractions, and fetal and maternal conditions. It explains how to identify abnormal labor progress and provides guidance on management for different scenarios, such as when labor is between the alert and action lines or beyond the action line. The goal is to use the partograph as a tool to help safely manage labor.
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 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 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.
Similar to Ginaasthmamanagement 110401035750-phpapp01 (20)
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
- 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
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
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).
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
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
1. POCKET GUIDE FOR
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ASTHMA MANAGEMENT
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AND PREVENTION
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(for Adults and Children Older than 5 Years)
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®
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A Pocket Guide for Physicians and Nurses
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Updated 2010
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BASE D ON THE GLOBAL STRATEGY FOR ASTHMA
MANAGEMENT AND PREVENTION
3. TABLE OF CONTENTS
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PREFACE .......................................................................................2
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WHAT IS KNOWN ABOUT ASTHMA?...........................................4
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DIAGNOSING ASTHMA ..............................................................6
Figure 1. Is it Asthma? ........................................................6
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CLASSIFICATION OF ASTHMA BY LEVEL OF CONTROL ...............8
Figure 2. Levels of Asthma Control.........................................8
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FOUR COMPONENTS OF ASTHMA CARE .....................................9
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Component 1. Develop Patient/Doctor Partnership..................9
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Figure 3. Example of Contents of an Action Plan to Maintain
Asthma Control....................................................10
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Component 2. Identify and Reduce Exposure to Risk Factors..11
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Figure 4. Strategies for Avoiding Common Allergens and
Pollutants ............................................................11
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Component 3. Assess, Treat, and Monitor Asthma.................12
Figure 5. Management Approach Based on Control..............14
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Figure 6. Estimated Equipotent Doses of Inhaled
Glucocorticosteroids.............................................15
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Figure 7. Questions for Monitoring Asthma Care ..................17
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Component 4. Manage Exacerbations.....................................18
Figure 8. Severity of Asthma Exacerbations ..........................21
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SPECIAL CONSIDERATIONS IN MANAGING ASTHMA ..............22
Appendix A: Glossary of Asthma Medications - Controllers....23
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Appendix B: Combination Medications for Asthma ................24
Appendix C: Glossary of Asthma Medications - Relievers......25
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4. PREFACE
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Asthma is a major cause of chronic morbidity and mortality throughout
the world and there is evidence that its prevalence has increased
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considerably over the past 20 years, especially in children. The Global
Initiative for Asthma was created to increase awareness of asthma
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among health professionals, public health authorities, and the general
public, and to improve prevention and management through a concerted
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worldwide effort. The Initiative prepares scientific reports on asthma,
encourages dissemination and implementation of the recommendations,
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and promotes international collaboration on asthma research.
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The Global Initiative for Asthma offers a framework to achieve and
maintain asthma control for most patients that can be adapted to local
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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.
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The Global Initiative for Asthma program publications include:
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• Global Strategy for Asthma Management and Prevention (2010).
Scientific information and recommendations for asthma programs.
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• Global Strategy for Asthma Management and Prevention
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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 (2010). Summary of patient care
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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
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for pediatricians and other health care professionals.
• What You and Your Family Can Do About Asthma. An information
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booklet for patients and their families.
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Publications are available from www.ginasthma.org.
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This Pocket Guide has been developed from the Global Strategy for
Asthma Management and Prevention (Updated 2010). Technical
discussions of asthma, evidence levels, and specific citations from the
scientific literature are included in that source document.
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5. Acknowledgements:
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Grateful acknowledgement is given for unrestricted educational grants from
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AstraZeneca, Boehringer Ingelheim, Chiesi Group, GlaxoSmithKline, MEDA
Pharma, Merck Sharp & Dohme, Mitsubishi Tanabe Pharma, Novartis,
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Nycomed, and Schering-Plough. 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
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Committee participants are solely responsible for the statements and
conclusions in the publications.
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6. WHAT IS KNOWN
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ABOUT ASTHMA?
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Unfortunately… asthma is one of the most common chronic diseases,
with an estimated 300 million individuals affected worldwide. Its
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prevalence is increasing, especially among children.
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Fortunately… asthma can be effectively treated and most patients can
achieve good control of their disease. When asthma is under control
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patients can:
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Avoid troublesome symptoms night and day
Use little or no reliever medication
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Have productive, physically active lives
Have (near) normal lung function
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Avoid serious attacks
• Asthma causes recurring episodes of wheezing, breathlessness,
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chest tightness, and coughing, particularly at night or in the early
morning.
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• Asthma is a chronic inflammatory disorder of the airways.
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Chronically inflamed airways are hyperresponsive; they become
obstructed and airflow is limited (by bronchoconstriction, mucus plugs,
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and increased inflammation) when airways are exposed to various
risk factors.
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• 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,
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respiratory (viral) infections, exercise, strong emotional expressions,
chemical irritants, and drugs (such as aspirin and beta blockers).
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• A stepwise approach to pharmacologic treatment to achieve and
maintain control of asthma should take into account the safety of
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treatment, potential for adverse effects, and the cost of treatment required
to achieve control.
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• Asthma attacks (or exacerbations) are episodic, but airway inflammation
is chronically present.
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7. • For many patients, controller medication must be taken daily to
prevent symptoms, improve lung function, and prevent attacks.
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Reliever medications may occasionally be required to treat acute
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symptoms such as wheezing, chest tightness, and cough.
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• To reach and maintain asthma control requires the development of a
partnership between the person with asthma and his or her health
care team.
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• Asthma is not a cause for shame. Olympic athletes, famous leaders,
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other celebrities, and ordinary people live successful lives with asthma.
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8. DIAGNOSING
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ASTHMA
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Asthma can often be diagnosed on the basis of a patient’s symptoms
and medical history (Figure 1).
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Figure 1. Is It Asthma?
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Presence of any of these signs and symptoms should increase the suspicion of asthma:
I Wheezing—high-pitched whistling sounds when breathing out—especially in children.
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(A normal chest examination does not exclude asthma.)
I History of any of the following:
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• Cough, worse particularly at night
• Recurrent wheeze
• Recurrent difficult breathing ta
• Recurrent chest tightness
I Symptoms occur or worsen at night, awakening the patient.
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I Symptoms occur or worsen in a seasonal pattern.
I The patient also has eczema, hay fever, or a family history of asthma or atopic
diseases.
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I Symptoms occur or worsen in the presence of:
• Animals with fur
• Aerosol chemicals
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• Changes in temperature
• Domestic dust mites
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• Drugs (aspirin, beta blockers)
• Exercise
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• Pollen
• Respiratory (viral) infections
• Smoke
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• Strong emotional expression
I Symptoms respond to anti-asthma therapy.
I Patient’s colds “go to the chest” or take more than 10 days to clear up.
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Measurements of lung function provide an assessment of the severity,
reversibility, and variability of airflow limitation, and help confirm the
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diagnosis of asthma.
Spirometry is the preferred method of measuring airflow limitation and
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its reversibility to establish a diagnosis of asthma.
• An increase in FEV1 of ≥ 12% and ≥200 ml after administration of a
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bronchodilator indicates reversible airflow limitation consistent with
asthma. (However, most asthma patients will not exhibit reversibility
at each assessment, and repeated testing is advised.)
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9. 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
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best measurements using his/her own peak flow meter.
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• An improvement of 60 L/min (or ≥ 20% of the pre-bronchodilator PEF)
after inhalation of a bronchodilator, or diurnal variation in PEF of
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more than 20% (with twice-daily readings, more than 10%), suggests
a diagnosis of asthma.
Additional diagnostic tests:
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• For patients with symptoms consistent with asthma, but normal lung
function, measurements of airway responsiveness to methacho-
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line and histamine, an indirect challenge test such as inhaled manni-
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tol, 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
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diagnosis of asthma, and can help to identify risk factors that cause
asthma symptoms in individual patients.
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Diagnostic Challenges
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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
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and airway hyperresponsiveness are particularly important.
Exercise-induced bronchoconstriction. Physical activity is an
important cause of asthma symptoms for most asthma patients, and
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for some (including many children) it is the only cause. Exercise testing
with an 8-minute running protocol can establish a firm diagnosis of
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asthma.
Children 5 Years and Younger. Not all young children who
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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
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Management and Prevention in Children 5 Years and Younger for
further details).
Asthma in the elderly. Diagnosis and treatment of asthma in the
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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
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asthma from COPD is particularly difficult, and may require a trial
of treatment.
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Occupational asthma. Asthma acquired in the workplace is a diagnosis
that is frequently missed. The diagnosis requires a defined history of
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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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10. CLASSIFICATION OF ASTHMA
BY LEVEL OF CONTROL
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The goal of asthma care is to achieve and maintain control of the clini-
cal manifestations of the disease for prolonged periods. When asthma is
controlled, patients can prevent most attacks, avoid troublesome symptoms
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day and night, and keep physically active.
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The assessment of asthma control should include control of the clinical man-
ifestations and control of the expected future risk to the patient such as
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exacerbations, accelerated decline in lung function, and side-effects of
treatment. In general, the achievement of good clinical control of asthma
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leads to reduced risk of exacerbations.
Figure 2 describes the clinical characteristics of controlled, partly con-
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trolled, and uncontrolled asthma.
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Figure 2. LEVELS OF ASTHMA CONTROL
A. Assessment of current clinical control (preferably over 4 weeks)
Characteristic Controlled Partly Controlled Uncontrolled
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(All of the following) (Any measure present)
Daytime symptoms None (twice or More than twice/week Three or more features of
less/week) partly controlled
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asthma*†
Limitation of activities None Any
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Nocturnal None Any
symptoms/awakening
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Need for reliever/ None (twice or More than twice/week
rescue treatment less/week)
Lung function (PEF or Normal 80% predicted or
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FEV1)‡ 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:
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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
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‡ Without administration of bronchodilator, lung function is not a reliable test for children 5 years and younger
Examples of validated measures for assessing clinical control of asthma include:
• Asthma Control Test (ACT): www.asthmacontrol.com
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• Childhood Asthma Control test (C-Act)
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• Asthma Control Questionnaire (ACQ): www.qoltech.co.uk/Asthma1.htm
• Asthma Therapy Assessment Questionnaire (ATAQ):
www.ataqinstrument.com
• Asthma Control Scoring System
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11. FOUR COMPONENTS OF
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ASTHMA CARE
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Four interrelated components of therapy are required to achieve and main-
tain control of asthma
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Component 1. Develop patient/doctor partnership
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Component 2. Identify and reduce exposure to risk factors
Component 3. Assess, treat, and monitor asthma
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Component 4. Manage asthma exacerbations
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Component 1: Develop Patient/Doctor Partnership
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The effective management of asthma requires the development of a
partnership between the person with asthma and his or her health care team.
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With your help, and the help of others on the health care team, patients
can learn to:
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• Avoid risk factors
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• Take medications correctly
• Understand the difference between “controller” and “reliever” medications
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• Monitor their status using symptoms and, if relevant, PEF
• Recognize signs that asthma is worsening and take action
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• Seek medical help as appropriate
Education should be an integral part of all interactions between health
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care professionals and patients. Using a variety of methods—such as
discussions (with a physician, nurse, outreach worker, counselor, or educa-
tor), demonstrations, written materials, group classes, video or audio tapes,
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dramas, and patient support groups—helps reinforce educational messages.
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Working together, you and your patient should prepare a written
personal asthma action plan that is medically appropriate and
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practical. A sample asthma plan is shown in Figure 3.
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12. Additional self-management plans can be found on several Websites,
including:
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www.asthma.org.uk
www.nhlbisupport.com/asthma/index.html
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www.asthmanz.co.nz
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Figure 3. Example of Contents of an Action Plan to Maintain Asthma Control
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Your Regular Treatment:
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1. Each day take ___________________________
2. Before exercise, take _____________________
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WHEN TO INCREASE TREATMENT
Assess your level of Asthma Control ta
In the past week have you had:
Daytime asthma symptoms more than 2 times? No Yes
Activity or exercise limited by asthma? No Yes
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Waking at night because of asthma? No Yes
The need to use your [rescue medication] more than 2 times? No Yes
If you are monitoring peak flow, peak flow less than______? No Yes
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If you answered YES to three or more of these questions, your asthma is
uncontrolled and you may need to step up your treatment.
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HOW TO INCREASE TREATMENT
STEP UP your treatment as follows and assess improvement every day:
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_________________________________ [Write in next treatment step here]
Maintain this treatment for _____________ days [specify number]
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WHEN TO CALL THE DOCTOR/CLINIC.
Call your doctor/clinic: _______________ [provide phone numbers]
If you don’t respond in _________ days [specify number]
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____________________________ [optional lines for additional instruction]
EMERGENCY/SEVERE LOSS OF CONTROL
If you have severe shortness of breath, and can only speak in short sentences,
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If you are having a severe attack of asthma and are frightened,
If you need your reliever medication more than every 4 hours and are not
improving.
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1. Take 2 to 4 puffs ___________ [reliever medication]
2. Take ____mg of ____________ [oral glucocorticosteroid]
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3. Seek medical help: Go to ________________; Address______________
Phone: _______________________
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4. Continue to use your _________ [reliever medication] until you are able to
get medical help.
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13. Component 2: Identify and Reduce Exposure to Risk
Factors
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To improve control of asthma and reduce medication needs, patients
should take steps to avoid the risk factors that cause their asthma symptoms
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(Figure 4). However, many asthma patients react to multiple factors that
are ubiquitous in the environment, and avoiding some of these factors
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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.
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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 2-agonist before strenuous exercise (a leukotriene
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modifier or cromone are alternatives).
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Patients with moderate to severe asthma should be advised to receive an
influenza vaccination every year, or at least when vaccination of the
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general population is advised. Inactivated influenza vaccines are safe for
adults and children over age 3.
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Figure 4. Strategies for Avoiding Common Allergens and Pollutants
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Avoidance measures that improve control of asthma and reduce medication needs:
• Tobacco smoke: Stay away from tobacco smoke. Patients and parents should
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not smoke.
• Drugs, foods, and additives: Avoid if they are known to cause symptoms.
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• 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:
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• House dust mites: Wash bed linens and blankets weekly in hot water and
dry in a hot dryer or the sun. Encase pillows and mattresses in air-tight covers.
Replace carpets with hard flooring, especially in sleeping rooms. (If possible, use
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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
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from the sleeping area. Wash the pet.)
• Cockroaches: Clean the home thoroughly and often. Use pesticide spray—but
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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.
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• Indoor mold: Reduce dampness in the home; clean any damp areas frequently.
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14. Component 3: Assess, Treat, and Monitor Asthma
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The goal of asthma treatment—to achieve and maintain clinical control—
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can be reached in most patients through a continuous cycle that involves
• Assessing Asthma Control
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• Treating to Achieve Control
• Monitoring to Maintain Control
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Assessing Asthma Control
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Each patient should be assessed to establish his or her current treatment
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regimen, adherence to the current regimen, and level of asthma control.
A simplified scheme for recognizing controlled, partly controlled, and
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uncontrolled asthma is provided in Figure 2.
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Treating to Achieve Control
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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.
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At each treatment step, reliever medication should be provided for
quick relief of symptoms as needed. (However, be aware of how much
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reliever medication the patient is using—regular or increased use indicates
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that asthma is not well controlled.)
At Steps 2 through 5, patients also require one or more regular controller
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medications, which keep symptoms and attacks from starting. Inhaled
glucocorticosteroids (Figure 6) are the most effective controller medications
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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,
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at Step 3). If asthma is not controlled on the current treatment regimen,
treatment should be stepped up until control is achieved.
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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
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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
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symptoms as possible—while minimizing the potential for adverse effects
from treatment. Referral to an asthma specialist may be helpful.
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15. A variety of controller (Appendix A and Appendix B) and reliever
(Appendix C) medications for asthma are available. The recommended
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treatments are guidelines only. Local resources and individual patient
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circumstances should determine the specific therapy prescribed for each
patient.
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Inhaled medications are preferred because they deliver drugs directly to
the airways where they are needed, resulting in potent therapeutic effects
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with fewer systemic side effects. Inhaled medications for asthma are available
as pressurized metered-dose inhalers (pMDIs), breath-actuated MDIs, dry
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powder inhalers (DPIs), and nebulizers. Spacer (or valved holding-chamber)
devices make inhalers easier to use and reduce systemic absorption and
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side effects of inhaled glucocorticosteroids.
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Teach patients (and parents) how to use inhaler devices. Different devices
need different inhalation techniques. ta
• Give demonstrations and illustrated instructions.
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• 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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16. Figure 5. Management Approach Based On Control
Management Approach Based On Control
Adults and Children Older than 5 Years
For Children Older Than 5 Years, Adolescents and Adults
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Reduce
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Level of Control Treatment Action
Controlled Maintain and find lowest controlling step
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Partly controlled Consider stepping up to gain control
Increase
Uncontrolled Step up until controlled
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Exacerbation Treat as exacerbation
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Reduce Treatment Steps Increase
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Step 1 Step 2 Step 3 Step 4 Step 5
Asthma education
Environmental control ta
As needed rapid-
As needed rapid-acting β2-agonist
acting β2-agonist
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To Step 3 treatment, To Step 4 treatment,
Select one Select one select one or more add either
Medium-or high-dose
Low-dose inhaled Low-dose ICS plus Oral glucocorticosteroid
ICS plus long-acting
ICS* long-acting β2-agonist (lowest dose)
β2-agonist
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Controller
options*** Leukotriene Medium-or Leukotriene Anti-IgE
modifier* high-dose ICS modifier treatment
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Low-dose ICS plus Sustained release
leukotriene modifier theophylline
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Low-dose ICS plus
sustained release
theophylline
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* ICS = inhaled glucocorticosteroids
**= Receptor antagonist or synthesis inhibitors
*** = Preferred controller options are shown in shaded boxes
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Alternative reliever treatments include inhaled anticholinergics, short-acting oral 2-agonists,
some long-acting 2-agonists, and short-acting theophylline. Regular dosing with short and
long-acting 2-agonist is not advised unless accompanied by regular use of an inhaled
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glucocorticosteroid.
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17. Figure 6. Estimated Equipotent Daily Doses of Inhaled
Glucocorticosteroids for Adults and Children Older than 5 Years †
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Drug
Low Dose (g)†
Medium Daily Dose (g)†
High Daily Dose (g)†
Beclomethasone 200-500 500-1000 1000-2000
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dipropionate
Budesonide* 200-400 400-800 800-1600
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Ciclesonide* 80-160 160-320 320-1280
Flunisolide 500-1000 1000-2000 2000
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Fluticasone 100-250 250-500 500-1000
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propionate
Mometasone 200-400 400-800 800-1200
furoate*
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Triamcinolone 400-1000 1000-2000 2000
acetonide ta
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† Comparisons based upon 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
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controllers. Maximum recommended doses are arbitrary but with prolonged use are associ-
ated with increased risk of systemic side effects.
* Approved for once-daily dosing in mild patients.
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Notes
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• The most important determinant of appropriate dosing is the clinicians judgment of the
patients response to therapy. The clinician must monitor the patients response in terms
of clinical control and adjust the dose accordingly. Once control of asthma is achieved,
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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 recommen-
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dations where possible. Clear demonstration of dose-response relationships is seldom
provided or available. The principle is therefore to establish the minimum effective con-
trolling dose in each patient, as higher doses may not be more effective and are likely to
be associated with greater potential for adverse effects.
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• 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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18. Monitoring to Maintain Control
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Ongoing monitoring is essential to maintain control and establish the
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lowest step and dose of treatment to minimize cost and maximize safety.
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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.
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At each visit, ask the questions listed in Figure 7.
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Adjusting medication:
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• If asthma is not controlled on the current treatment regimen, step up
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treatment. Generally, improvement should be seen within 1 month.
But first review the patient’s medication technique, compliance, and
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avoidance of risk factors.
• If asthma is partly controlled, consider stepping up treatment,
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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.
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• If control is maintained for at least 3 months, step down with a
gradual, stepwise reduction in treatment. The goal is to decrease
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treatment to the least medication necessary to maintain control.
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Monitoring is still necessary even after control is achieved, as asthma is
a variable disease; treatment has to be adjusted periodically in response
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to loss of control as indicated by worsening symptoms or the development
of an exacerbation.
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19. Figure 7. Questions for Monitoring Asthma Care
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IS THE ASTHMA MANAGEMENT PLAN MEETING EXPECTED GOALS?
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Ask the patient: Action to consider:
Has your asthma awakened you at
night?
Adjust medications and management
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plan as needed (step up or step down).
Have you needed more reliever But first, compliance should be
medications than usual? assessed.
Have you needed any urgent medical
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care?
Has your peak flow been below your
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personal best?
Are you participating in your usual
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physical activities?
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IS THE PATIENT USING INHALERS, SPACER, OR
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PEAK FLOW METERS CORRECTLY?
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Ask the patient: Action to consider:
Please show me how you take your
medicine.
Demonstrate correct technique.
Have patient demonstrate back.
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IS THE PATIENT TAKING THE MEDICATIONS AND AVOIDING RISK
FACTORS ACCORDING TO THE ASTHMA MANAGEMENT PLAN?
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Ask the patient, for example: Action to consider:
So that we may plan therapy, please
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tell me how often you actually take
Adjust plan to be more practical.
the medicine.
Problem solve with the patient to over-
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come barriers to following the plan.
What problems have you had follow-
ing the management plan or taking
your medication?
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During the last month, have you ever
stopped taking your medicine
because you were feeling better?
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DOES THE PATIENT HAVE ANY CONCERNS?
Ask the patient: Action to consider:
What concerns might you have
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about your asthma, medicines, or
Provide additional education to relieve
management plan?
concerns and discussion to overcome
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barriers.
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20. Component 4: Manage Exacerbations
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Exacerbations of asthma (asthma attacks) are episodes of a progressive
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increase in shortness of breath, cough, wheezing, or chest tightness, or a
combination of these symptoms.
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Do not underestimate the severity of an attack; severe asthma
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attacks may be life threatening. Their treatment requires close supervision.
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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
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exacerbations. These patients include those:
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• With a history of near-fatal asthma requiring intubation and mechanical
ventilation ta
• Who have had a hospitalization or emergency visit for asthma within
the past year
no
• Who are currently using or have recently stopped using oral gluco-
corticosteroids
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• Who are not currently using inhaled glucocorticosteroids
• Who are overdependent on rapid-acting inhaled 2-agnoists, especially
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those who use more than one canister of salbutamol (or equivalent)
monthly
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• With a history of psychiatric disease or psychosocial problems, including
the use of sedatives
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• With a history of noncompliance with an asthma medication plan
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Patients should immediately seek medical care if:
• The attack is severe (Figure 8):
hte
- The patient is breathless at rest, is hunched forward, talks in
words rather than sentences (infant stops feeding), is agitated,
rig
drowsy, or confused, has bradycardia, or has a respiratory rate
greater than 30 per minute
py
- Wheeze is loud or absent
- Pulse is greater than 120/min (greater than 160/min for infants)
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- PEF is less than 60 percent of predicted or personal best, even
after initial treatment
- The patient is exhausted
18
21. • 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
e
glucocorticosteroid treatment is started
uc
• 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 use of rapid-acting 2-agonists, can usually be
ep
treated at home if the patient is prepared and has a personal asthma
management plan that includes action steps.
rr
ro
Moderate attacks may require, and severe attacks usually require, care in
a clinic or hospital.
lte
Asthma attacks require prompt treatment:
ta
• Inhaled rapid-acting 2-agonists in adequate doses are essential.
(Begin with 2 to 4 puffs every 20 minutes for the first hour; then mild
no
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
do
during a 24-hour period) introduced early in the course of a moderate or
severe attack help to reverse the inflammation and speed recovery.
l-
• Oxygen is given at health centers or hospitals if the patient is hypoxemic
(achieve O2 saturation of 95%).
ria
• Combination 2-agonist/anticholinergic therapy is associated with lower
hospitalization rates and greater improvement in PEF and FEV1.
ate
• Methylxanthines are not recommended if used in addition to high doses
of inhaled 2-agonists. However, theophylline can be used if inhaled
2-agonists are not available. If the patient is already taking theophylline
dm
on a daily basis, serum concentration should be measured before adding
short-acting theophylline.
• Patients with severe asthma exacerbations unresponsive to bronchodilators
hte
and systemic glucocorticosteroids, 2 grams of magnesium sulphate IV has
been shown to reduce the need for hospitalizations.
rig
Therapies not recommended for treating asthma attacks include:
py
• Sedatives (strictly avoid)
• Mucolytic drugs (may worsen cough)
Co
• 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)
19
22. • Antibiotics (do not treat attacks but are indicated for patients who also
have pneumonia or bacterial infection such as sinusitis)
e
• Epinephrine/adrenaline (may be indicated for acute treatment of
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anaphylaxis and angioedema but is not indicated for asthma attacks)
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Monitor response to treatment:
ep
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
rr
flow 30-50 percent predicted.
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Follow up:
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After the exacerbation is resolved, the factors that precipitated the
exacerbation should be identified and strategies for their future avoidance
ta
implemented, and the patient’s medication plan reviewed.
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do
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20
23. Figure 8. Severity of Asthma Exacerbations*
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Parameter Mild Moderate Severe Respiratory
arrest imminent
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Breathless Walking Talking At rest
Infant - softer, shorter Infant stops
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cry; difficulty feeding feeding
Can lie down Prefer sitting Hunched forward
Talks in Sentences Phrases Words
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Alertness May be agitated Usually agitated Usually agitated Drowsy or confused
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Respiratory rate Increased Increased Often 30/min
Normal rates of breathing in awake children:
Age Normal rate
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2 months 60/min
2-12 months 50/min
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1-5 years 40/min
6-8 years 30/min
Accessory muscles
and suprasternal
Usually not Usually
ta Usually Paradoxical
thoraco-abdominal
retractions movement
no
Wheeze Moderate, often Loud Usually loud Absence of
only and expiratory wheeze
Pulse/min. 100 100-120 120 Bradycardia
do
Guide to limits of normal pulse rate in children:
Infants 2-12 months -Normal rate 160/min
Preschool 1-2 years -Normal rate 120/min
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School age 2-8 years -Normal rate 110/min
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Pulsus paradoxus Absent May be present Often present Absence suggests
10 mm Hg 10-25 mm Hg 25 mm Hg (adult) respiratory muscle
20-40 mm Hg (child) fatigue
ate
PEF Over 80% Approx. 60-80% 60% predicted or
after initial personal best
bronchodilator ( 100 L/min adults)
dm
% predicted or or
% personal best response lasts 2 hrs
PaO2 (on air)† Normal 60 mm Hg 60 mm Hg
Test not usually
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necessary Possible cyanosis
and/or
paCO2† 45 mm Hg 45 mm Hg 45 mm Hg;
Possible respiratory
failure (see text)
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SaO2% (on air)† 95% 91-95% 90%
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Hypercapnia (hypoventilation) develops more readily in young children than in adults and adolescents.
*Note: The presence of several parameters, but not necessarily all, indicates the general classification of the exacerbation.
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†Note: Kilopascals are also used internationally, conversion would be appropriate in this regard.
21
24. SPECIAL CONSIDERATIONS
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IN MANAGING ASTHMA
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Pregnancy. During pregnancy the severity of asthma often changes, and
patients may require close follow-up and adjustment of medications. Pregnant
ep
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
rr
aggressively to avoid fetal hypoxia.
Obesity. Management of asthma in the obese should be the same as patients
ro
with normal weight. Weight loss in the obese patient improves asthma
control, lung function and reduces medication needs.
lte
Surgery. Airway hyperresponsiveness, airflow limitation, and mucus hyper-
secretion predispose patients with asthma to intraoperative and postoperative
ta
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
no
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.
do
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
l-
responsive to topical glucocorticosteroids.
Occupational asthma. Pharmacologic therapy for occupational asthma
ria
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
ate
asthma management or occupational medicine is advisable.
Respiratory infections. Respiratory infections provoke wheezing and
increased asthma symptoms in many patients. Treatment of an infectious
dm
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 antagorists or surgery fail to improve asthma
hte
control.
Aspirin-induced asthma. Up to 28 percent of adults with asthma, but
rarely children, suffer from asthma exacerbations in response to aspirin
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and other nonsteroidal anti-inflammatory drugs. The diagnosis can only be
confirmed by aspirin challenge, which must be conducted in a facility with
py
cardiopulmonary resuscitation capabilities. Complete avoidance of the drugs
that cause symptoms is the standard management.
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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.
22
25. Appendix A: Glossary of Asthma Medications - Controllers
Name and Usual Doses Side Effects Comments
e
Also Known As
uc
Glucocortico- Inhaled: Beginning Inhaled: High daily doses Inhaled: Potential but small
steroids dose dependent on may be associated with skin risk of side effects is well
Adrenocorticoids asthma control then thinning and bruises, and balanced by efficacy. Valved
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Corticosteroids titrated down over rarely adrenal suppression. holding-chambers with MDIs
Glucocorticoids 2-3 months to lowest Local side effects are hoarse- and mouth washing with DPIs
effective dose once ness and oropharyngeal after inhalation decrease oral
Inhaled (ICS): control is achieved. candidiasis. Low to medium Candidiasis. Preparations not
ep
Beclomethasone doses have produced minor equivalent on per puff or g
Budesonide growth delay or suppression basis.
Ciclesonide Tablets or syrups: (av. 1cm) in children. Attainment
Flunisolide For daily control use of predicted adult height does
rr
Fluticasone lowest effective dose not appear to be affected. Tablet or syrup: Long
Mometasone 5-40 mg of prednisone term use: alternate day a.m.
Triamcinolone equivalent in a.m. or dosing produces less toxicity.
ro
qod. Tablets or syrups: Used Short term: 3-10 day “bursts”
Tablets or syrups: long term, may lead to are effective for gaining
hydrocortisone For acute attacks osteoporosis, hypertension, prompt control.
methylprednisolone
lte
40-60 mg daily in diabetes, cataracts, adrenal
prednisolone 1 or 2 divided doses suppression, growth suppression,
prednisone for adults or 1-2 mg/kg obesity, skin thinning or muscle
daily in children. weakness. Consider coexisting
ta
conditions that could be
worsened by oral glucocortico-
steroids, e.g. herpes virus
no
infections, Varicella,
tuberculosis, hypertension,
diabetes and osteoporosis
do
Sodium MDI 2 mg or 5 mg Minimal side effects. Cough May take 4-6 weeks to
cromoglycate 2-4 inhalations 3-4 may occur upon inhalation. determine maximum effects.
cromolyn times daily. Nebulizer Frequent daily dosing
cromones 20 mg 3-4 times daily. required.
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Nedocromil MDI 2 mg/puff 2-4 Cough may occur upon Some patients unable to
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cromones inhalations 2-4 times inhalation. tolerate the taste.
daily.
ate
Long-acting Inhaled: Inhaled: fewer, and less Inhaled: Salmeterol NOT to
2-agonists DPI -F: 1 inhalation significant, side effects than be used to treat acute attacks.
beta-adrenergis (12 g) bid. tablets. Have been associated Should not use as mono-
sympathomimetics MDI- F: 2 puffs bid. with an increased risk of therapy for controller therapy.
dm
LABAs DPI-Sm: 1 inhalation severe exacerbations and Always use as adjunct to
(50 g) bid. asthma deaths when added ICS therapy. Formoterol has
Inhaled: MDI-Sm: 2 puffs bid. to usual therapy. onset similar to salbutamol
Formoterol (F) and has been used as needed
Salmeterol (Sm) for acute symptoms.
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Tablets: Tablets: may cause
Sustained-release S: 4 mg q12h. tachycardia, anxiety, skeletal Tablets: As effective as
Tablets: T: 10mg q12h. muscle tremor, headache, sustained-release theophylline.
Salbutamol (S) hypokalemia. No data for use as adjunctive
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Terbutaline (T) Starting dose 10 therapy with inhaled
Aminophylline mg/kg/day with Nausea and vomiting are glucocorticosteroids.
methylxanthine usual 800 mg most common. Serious effects
xanthine maximum in occurring at higher serum Theophylline level monitoring
py
1-2 divided doses. concentrations include is often required. Absorption
seizures, tachycardia, and and metabolism may be
arrhythmias. affected by many factors,
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including febrile illness.
Table continued...
23
26. Appendix A: Glossary of Asthma Medications - Controllers (continued...)
Name and Usual Doses Side Effects Comments
Also Known As
e
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Antileukotrienes Adults: M 10mg qhs No specific adverse effects Antileukotrienes are most
Leukotriene modifiers P 450mg bid to date at recommended effective for patients with
Montelukast (M) Z 20mg bid; doses. Elevation of liver mild persistent asthma. They
enzymes with Zafirlukast provide additive benefit when
r od
Pranlukast (P) Zi 600mg qid.
Zafirlukast (Z) and Zileuton and limited added to ICSs though not as
Zileuton (Zi) Children: M 5 mg case reports of reversible effective as inhaled long-acting
qhs (6-14 y) hepatitis and hyperbiliru- 2-agonists.
M 4 mg qhs (2-5 y) binemia with Zileuton and
ep
Z 10mg bid (7-11 y). hepatic failure with afirlukast
Immunomodulators Adults: Dose Pain and bruising at injec- Need to be stored under
rr
Omalizumab administered subcu- tion site (5-20%) and very refrigeration 2-8˚C and
Anti-IgE taneously every 2 or 4 rarely anaphylaxis (0.1%). maximum of 150 mg
weeks dependent administered per injection site.
ro
on weight and IgE
concentration
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Appendix B: Combination Medications For Asthma
ta
Formulation Inhaler Devices Doses Inhalations/day Therapeutic
Available Use
( g)1 ICS/LABA
no
Fluticasone DPI 100/501 1 inhalation x 2 Maintenance
propionate/ 250/50
salmeterol 500/50
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Fluticasone pMDI 50/251 2 inhalations x 2 Maintenance
propionate/ (Suspension) 125/25
salmeterol 250/25
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Budesonide/ DPI 80/4.52 1-2 inhalations x 2 Maintenance
formoterol 160/4.5 and Relief
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320/9.0
Budesonide/ pMDI 80/4.52 2 inhalations x 2 Maintenance
ate
formoterol (Suspension) 160/4.5
Beclomethasone/ pMDI 100/63 1-2 inhalations x 2 Maintenance
formoterol (Solution)
dm
Mometasone/ pMDI 100/5 2 inhalations x 2 Maintenance
formoterol 200/5
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ICS = inhaled corticosteroid; LABA = long acting -agonist; pMDI = pressurized metered dose inhaler; DPI = dry powder inhaler
2
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.
rig
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
py
representatives for products approved for use in your country.
2
Refers to delivered dose. For additional information about dosages and products available in specific
Co
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.
3
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.
24
27. Appendix C: Glossary of Asthma Medications - Relievers
e
Name and Also Usual Doses Side Effects Comments
Known As
uc
Short-acting Differences in potency Inhaled: tachycardia, Drug of choice for acute
2-agonists exist but all products skeletal muscle tremor, bronchospasm. Inhaled route
r od
Adrenergics are essentially headache, and irritability. has faster onset and is more
2-stimulants comparable on a per At very high dose hyper- effective than tablet or syrup.
Sympathomimetics puff basis. For pre glycemia, hypokalemia. Increasing use, lack of expected
symptomatic use and effect, or use of 1 canister
Albuterol/salbutamol pretreatment before Systemic administration as a month indicate poor asthma
ep
Fenoterol exercise 2 puffs MDI Tablets or Syrup increases control; adjust long-term
Levalbuterol or 1 inhalation DPI. the risk of these side effects. therapy accordingly. Use
Metaproterenol For asthma attacks of 2 canisters per month is
rr
Pirbuterol 4-8 puffs q2-4h, may associated with an increased
Terbutaline administer q20min x 3 risk of a severe, life-threatening
with medical supervi- asthma attack.
ro
sion or the equivalent
of 5 mg salbutamol
by nebulizer.
lte
Anticholinergics IB-MDI 4-6 puffs q6h or Minimal mouth dryness or May provide additive effects
Ipratropium q20 min in the emergency bad taste in the mouth. to 2-agonist but has slower
bromide (IB) department. Nebulizer ta onset of action. Is an alternative
Oxitropium 500 g q20min x 3 for patients with intolerance
bromide then q2-4hrs for adults for 2-agonists.
and 250-500 g for
no
children.
Short-acting 7 mg/kg loading Nausea, vomiting, headache. Theophylline level monitoring
theophylline dose over 20 min At higher serum concentra- is required. Obtain serum
Aminophylline followed by 0.4 tions: seizures, tachycardia, levels 12 and 24 hours into
do
mg/kg/hr continuous and arrhythmias. infusion. Maintain between
infusion. 10-15 g/mL.
Epinephrine/ 1:1000 solution Similar, but more significant In general, not recommended
l-
adrenaline (1mg/mL) .01mg/kg effects than selective 2-agonist. for treating asthma attacks if
injection up to 0.3-0.5 mg, can In addition: hypertension, selective 2-agonists are
give q20min x 3. fever, vomiting in children and available.
ria
hallucinations.
ate
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25
28. Co
py
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NOTES
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26
29. 27
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py
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NOTES
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e
30. The Global Initiative for Asthma is supported by educational grants from:
e
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Visit the GINA website at www.ginasthma.org
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www.ginasthma.org/application.asp
bc30
Copies of this document are available at