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
HỘI CHỨNG CHỒNG LẤP HEN PHẾ QUẢN VÀ COPD _ ACOSSoM
This document provides a step-wise approach to diagnosing chronic airflow limitation diseases such as asthma, COPD, and asthma-COPD overlap syndrome (ACOS). Step 1 involves determining if a patient has a chronic airways disease based on their medical history, physical exam, imaging, and screening questionnaires. Step 2 is a syndromic diagnosis categorizing the patient's features as favoring asthma, COPD, or ACOS. Step 3 is confirming with spirometry and Step 4 starting initial therapy. Step 5 refers patients for specialized tests if needed to distinguish between the conditions. ACOS is identified by features shared with both asthma and COPD.
This document summarizes some of the key changes in the 2017 versions of GINA (Global Initiative for Asthma) and GOLD (Global Strategy for Diagnosis, Management and Prevention of COPD). It discusses updates to the definitions of asthma and its diagnosis. The stepwise approach to asthma management has been updated, including adding sublingual immunotherapy as an optional add-on treatment for some adult patients. Other changes include guidance on stepping down treatment and side effects of oral corticosteroids.
This document provides an overview of the Global Initiative for Asthma (GINA) 2017 update. It outlines GINA's structure, objectives, and resources. Key points include:
- GINA aims to provide global asthma strategy recommendations for diagnosis, management, and prevention.
- It has a board of directors, science committee, and assembly of participating countries.
- Resources include the full GINA strategy report, pocket guides, and dissemination tools available on their website.
- The 2017 update focuses on areas like the asthma-COPD overlap, lung function assessments, FeNO measurements, and immunotherapy.
This document provides guidelines from the Global Initiative for Asthma (GINA) and the British Thoracic Society on the management of asthma. It discusses the diagnosis and classification of asthma, the components of asthma care including developing a treatment plan, identifying and reducing risk factors, assessing control and monitoring the condition. It outlines a stepwise approach to pharmacological treatment based on disease severity and control. Controller medications include inhaled corticosteroids, long-acting beta agonists, leukotriene modifiers and oral corticosteroids. Reliever medications like short-acting beta agonists are used for acute symptoms. The guidelines provide guidance on monitoring control and adjusting treatment accordingly.
This document 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
The document summarizes the Global Initiative for Asthma (GINA) strategy for managing asthma. It provides:
1) An overview of the GINA program, which takes a practical, evidence-based approach to managing asthma globally.
2) Details on key changes in the 2016 GINA strategy, including new treatment recommendations and a focus on low-resource settings.
3) Information on defining and diagnosing asthma, emphasizing the use of symptom history and tests to confirm variable airflow limitation.
The document summarizes the 2019 Global Initiative for Asthma (GINA) guidelines. Key changes from prior years include: (1) short-acting beta agonists alone are no longer recommended for initial treatment due to increased risk of severe exacerbations; (2) all adults and adolescents should receive low-dose inhaled corticosteroids to reduce exacerbation risk. The guidelines outline criteria for diagnosing asthma, assessing patients, developing treatment plans, adjusting medications based on control, and managing exacerbations. The overall goals of treatment are to reduce risks of death, exacerbations, airway damage and medication side effects.
HỘI CHỨNG CHỒNG LẤP HEN PHẾ QUẢN VÀ COPD _ ACOSSoM
This document provides a step-wise approach to diagnosing chronic airflow limitation diseases such as asthma, COPD, and asthma-COPD overlap syndrome (ACOS). Step 1 involves determining if a patient has a chronic airways disease based on their medical history, physical exam, imaging, and screening questionnaires. Step 2 is a syndromic diagnosis categorizing the patient's features as favoring asthma, COPD, or ACOS. Step 3 is confirming with spirometry and Step 4 starting initial therapy. Step 5 refers patients for specialized tests if needed to distinguish between the conditions. ACOS is identified by features shared with both asthma and COPD.
This document summarizes some of the key changes in the 2017 versions of GINA (Global Initiative for Asthma) and GOLD (Global Strategy for Diagnosis, Management and Prevention of COPD). It discusses updates to the definitions of asthma and its diagnosis. The stepwise approach to asthma management has been updated, including adding sublingual immunotherapy as an optional add-on treatment for some adult patients. Other changes include guidance on stepping down treatment and side effects of oral corticosteroids.
This document provides an overview of the Global Initiative for Asthma (GINA) 2017 update. It outlines GINA's structure, objectives, and resources. Key points include:
- GINA aims to provide global asthma strategy recommendations for diagnosis, management, and prevention.
- It has a board of directors, science committee, and assembly of participating countries.
- Resources include the full GINA strategy report, pocket guides, and dissemination tools available on their website.
- The 2017 update focuses on areas like the asthma-COPD overlap, lung function assessments, FeNO measurements, and immunotherapy.
This document provides guidelines from the Global Initiative for Asthma (GINA) and the British Thoracic Society on the management of asthma. It discusses the diagnosis and classification of asthma, the components of asthma care including developing a treatment plan, identifying and reducing risk factors, assessing control and monitoring the condition. It outlines a stepwise approach to pharmacological treatment based on disease severity and control. Controller medications include inhaled corticosteroids, long-acting beta agonists, leukotriene modifiers and oral corticosteroids. Reliever medications like short-acting beta agonists are used for acute symptoms. The guidelines provide guidance on monitoring control and adjusting treatment accordingly.
This document 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
The document summarizes the Global Initiative for Asthma (GINA) strategy for managing asthma. It provides:
1) An overview of the GINA program, which takes a practical, evidence-based approach to managing asthma globally.
2) Details on key changes in the 2016 GINA strategy, including new treatment recommendations and a focus on low-resource settings.
3) Information on defining and diagnosing asthma, emphasizing the use of symptom history and tests to confirm variable airflow limitation.
The document summarizes the 2019 Global Initiative for Asthma (GINA) guidelines. Key changes from prior years include: (1) short-acting beta agonists alone are no longer recommended for initial treatment due to increased risk of severe exacerbations; (2) all adults and adolescents should receive low-dose inhaled corticosteroids to reduce exacerbation risk. The guidelines outline criteria for diagnosing asthma, assessing patients, developing treatment plans, adjusting medications based on control, and managing exacerbations. The overall goals of treatment are to reduce risks of death, exacerbations, airway damage and medication side effects.
Stepwise Approach For Adjusting Asthma Treatment 2017 Ashraf ElAdawy
The document discusses asthma control and management. It provides tools for assessing asthma control, such as the Asthma Control Test. It identifies risk factors for exacerbations and poor outcomes. It also outlines the stepwise approach to asthma management, with Steps 1 through 5 representing increasing treatment intensity. Initial treatment is usually with a low-dose inhaled corticosteroid, but may be at a higher step depending on symptom frequency and risk factors. The preferred option for Step 3 treatment in children ages 6-11 is a medium-dose inhaled corticosteroid, while options for adults include increasing the corticosteroid dose or adding a long-acting beta-2 agonist or other controller.
Asthma 2010 new gina guidelines[pediatric]Pradeep Gc
This document provides information on asthma management guidelines and tools. It discusses the goals of asthma management, which include achieving control of symptoms, maintaining normal activity levels, pulmonary function, and preventing exacerbations and mortality. It outlines a six-part asthma management program involving education, assessment, avoiding triggers, medication plans, managing exacerbations, and follow-up care. Classification systems for severity are presented for children and adults. Peak flow meters, spirometry, inhaler devices, and stepwise treatment approaches are also summarized.
The Global Initiative for Asthma (GINA) aims to increase awareness of asthma as a global health problem, present recommendations for diagnosis and management, and provide strategies to adapt recommendations based on varying resources. GINA works with a global network to disseminate asthma programs. The key documents produced by GINA include the Global Strategy for Asthma Management and Prevention, which provides an evidence-based framework for diagnosis, treatment, and prevention of asthma. The strategy emphasizes a stepwise approach and partnership between patients and healthcare providers to achieve optimal asthma control and management.
GINA Guidelines is an Internationally accepted standard Guidelines for ASTHMA .
This Power Point Presentation includes 2019 updates and comparison between 2018 and 2019 guidelines.
This presentation is all about world asthma day which is celebrated every year. this year we celebrated it on 4th may 2021. here we can get information about when, why and how we celebrate along with signs & symptoms, diagnosis and prevention of asthama.
The document summarizes key changes and recommendations from the 2015 Global Initiative for Asthma (GINA) update, including:
- Add-on tiotropium by soft-mist inhaler is a new treatment option for Steps 4 and 5 in patients ≥18 years with exacerbation history.
- Management of asthma in pregnancy includes monitoring for infections and using usual controllers during labor/delivery.
- Dry powder inhalers can deliver SABA in mild-moderate exacerbations but not for severe acute asthma.
- For life-threatening asthma in primary care, give SABA, ipratropium, systemic corticosteroids, and oxygen while arranging transfer.
The document provides an overview of the Global Initiative for Asthma's 2019 strategy for asthma management and prevention. It discusses GINA's goals of reducing asthma prevalence, morbidity, and mortality. It also summarizes the key aspects of asthma including phenotypes, diagnosis, assessment of control and risk factors, and pharmacological and non-pharmacological treatment strategies. The treatment approach involves classifying asthma severity and control to determine the appropriate controller medications and adjusting the treatment regimen up or down as needed.
This document discusses guidelines from the Global Initiative for Asthma (GINA) for defining, describing, diagnosing and treating asthma. It provides definitions of asthma as a chronic inflammatory disease of the airways characterized by variable respiratory symptoms. It outlines the criteria for diagnosing asthma based on symptoms, lung function tests and response to treatment. It also discusses evaluating asthma control and severity, and establishing a treatment plan to control symptoms and reduce risks. The goal of treatment is to achieve good symptom control and maintain normal daily activity levels while decreasing risks of exacerbations and adverse effects.
GINA 2019: a fundamental change in asthma management Ashraf ElAdawy
Mild asthma accounts for 50-75% of the asthma population. While symptoms may be infrequent or mild, airway inflammation is still present and patients are at risk of exacerbations. Recent guidelines recommend low-dose inhaled corticosteroids as the preferred first-line treatment for mild asthma over short-acting beta agonists alone due to safety concerns around overreliance on reliever medications and risk of exacerbations. New studies provide evidence that symptom-driven use of combination inhalers containing an inhaled corticosteroid and long-acting beta agonist may be effective alternatives to regular maintenance treatment for mild asthma.
The document summarizes the Global Initiative for Asthma's 2019 strategy for managing asthma. It outlines that asthma is a heterogeneous disease characterized by chronic airway inflammation. It then discusses asthma phenotypes, diagnosis of asthma, assessing asthma control and risk factors, and treatment options. The treatment approach involves a stepwise approach starting with low dose inhaled corticosteroids and adding additional controllers as needed to control symptoms and reduce exacerbation risk. The 2019 update emphasizes adding inhaled corticosteroids for all patients rather than short-acting bronchodilators alone due to risks of exacerbations from the latter approach.
This document provides recommendations from the British guideline on the management of asthma. It recommends that the initial assessment of asthma in both children and adults should focus on taking a thorough clinical history and considering alternative diagnoses. For those with a high probability of asthma, treatment should be started, while further testing is reserved for poor responders. For intermediate probability cases, tests like lung function and a treatment trial can help determine if a diagnosis of asthma is appropriate. Self-management education and written asthma action plans are recommended to improve health outcomes.
Dr. Kumar Utsav presented an update on the Global Initiative for Asthma (GINA) 2017 guidelines. Key changes included adding sublingual immunotherapy as an add-on option for some patients, updating recommendations for severe asthma treatment including new biologics, and clarifying the use of fractional exhaled nitric oxide testing in diagnosis and management. The guidelines emphasize a practical clinical approach for managing asthma in both high and low-resource settings.
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.
The document summarizes a clinical trial that compared the effectiveness of adding montelukast (Singulair) versus salmeterol/fluticasone (Advair) or increasing the dose of fluticasone for children with uncontrolled asthma on low-dose inhaled corticosteroids. The BADGER trial found that adding salmeterol to fluticasone or increasing the fluticasone dose resulted in better asthma control compared to adding montelukast. However, some children responded better to montelukast. The document concludes that while several options exist, the patient's current level of control indicates a need to step up therapy beyond low-dose inhaled corticosteroids alone
This document provides an overview of acute asthma and recent evidence-based guidelines. It discusses the pathophysiology of asthma and clinical presentation. Updated guidelines from NAEPP, GINA, and ERS/ATS are presented which classify asthma severity and provide stepwise recommendations for pharmacological management. Key points include distinguishing between severe versus uncontrolled asthma, evaluating for treatment non-adherence and comorbidities before diagnosing severe asthma, and emphasizing environmental control and inhaler technique.
Serum magnesium level in children with bronchial asthma Azad Haleem
- The study aimed to determine the prevalence of hypomagnesemia (low magnesium levels) among asthmatic children compared to healthy controls.
- The mean serum magnesium level was found to be significantly lower in asthmatic children (1.91 mg/dL) than in healthy controls (2.03 mg/dL).
- Within the asthmatic group, serum magnesium levels decreased with increased asthma severity and inversely correlated with duration of asthma, though not significantly.
- The study concluded that asthmatic children have higher risk of magnesium deficiency and supplementation may help improve asthma outcomes.
this guideline based on recent articles by major education establishments concerned with building national guidelines. please dont be hurry to make comments about use of IV aminophylline. aminiphylline used under some extra care and when other treatment options are failing. benefits of those treatments yet remain controversial. IV aminophylline has its own risks including the possibility of toxicity.
This document discusses asthma in children and provides guidelines for diagnosis and management. It notes that most childhood asthma starts in the preschool years and can be classified into different phenotypes based on risk factors and symptoms. The goals of treatment are to control symptoms and prevent exacerbations. Spirometry can help diagnose and monitor asthma in children over 6 years old, while other tools like peak flow meters and exhaled nitric oxide can help in younger children. Treatment involves a stepwise approach starting with reliever medications and adding controller medications like inhaled corticosteroids based on symptom severity and risk of exacerbations. Close monitoring is important to maintain control and reduce medication doses if possible.
The document discusses the need for a refresher course on obstructive airways diseases (OAD) in India. It notes that OADs such as asthma and COPD represent a major health burden in India, with prevalence increasing. However, a large number of OAD cases remain undiagnosed due to underuse of spirometry testing and poor management of patients in clinical practice. Inhaler therapy is also not widely used properly. A refresher course could help address these issues to improve diagnosis and management of OADs in India.
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.
Este documento presenta información sobre las nuevas recomendaciones del GINA 2014 para el diagnóstico y tratamiento del asma. En 3 oraciones o menos:
1) El GINA busca aumentar la conciencia sobre el asma como problema de salud global, presentar recomendaciones clave para el diagnóstico y tratamiento, y proveer estrategias para adaptar las recomendaciones a diferentes contextos. 2) El documento describe los criterios para diagnosticar asma basados en síntomas e historia del paciente, así como pruebas objetivas como la reversibilidad del flu
Stepwise Approach For Adjusting Asthma Treatment 2017 Ashraf ElAdawy
The document discusses asthma control and management. It provides tools for assessing asthma control, such as the Asthma Control Test. It identifies risk factors for exacerbations and poor outcomes. It also outlines the stepwise approach to asthma management, with Steps 1 through 5 representing increasing treatment intensity. Initial treatment is usually with a low-dose inhaled corticosteroid, but may be at a higher step depending on symptom frequency and risk factors. The preferred option for Step 3 treatment in children ages 6-11 is a medium-dose inhaled corticosteroid, while options for adults include increasing the corticosteroid dose or adding a long-acting beta-2 agonist or other controller.
Asthma 2010 new gina guidelines[pediatric]Pradeep Gc
This document provides information on asthma management guidelines and tools. It discusses the goals of asthma management, which include achieving control of symptoms, maintaining normal activity levels, pulmonary function, and preventing exacerbations and mortality. It outlines a six-part asthma management program involving education, assessment, avoiding triggers, medication plans, managing exacerbations, and follow-up care. Classification systems for severity are presented for children and adults. Peak flow meters, spirometry, inhaler devices, and stepwise treatment approaches are also summarized.
The Global Initiative for Asthma (GINA) aims to increase awareness of asthma as a global health problem, present recommendations for diagnosis and management, and provide strategies to adapt recommendations based on varying resources. GINA works with a global network to disseminate asthma programs. The key documents produced by GINA include the Global Strategy for Asthma Management and Prevention, which provides an evidence-based framework for diagnosis, treatment, and prevention of asthma. The strategy emphasizes a stepwise approach and partnership between patients and healthcare providers to achieve optimal asthma control and management.
GINA Guidelines is an Internationally accepted standard Guidelines for ASTHMA .
This Power Point Presentation includes 2019 updates and comparison between 2018 and 2019 guidelines.
This presentation is all about world asthma day which is celebrated every year. this year we celebrated it on 4th may 2021. here we can get information about when, why and how we celebrate along with signs & symptoms, diagnosis and prevention of asthama.
The document summarizes key changes and recommendations from the 2015 Global Initiative for Asthma (GINA) update, including:
- Add-on tiotropium by soft-mist inhaler is a new treatment option for Steps 4 and 5 in patients ≥18 years with exacerbation history.
- Management of asthma in pregnancy includes monitoring for infections and using usual controllers during labor/delivery.
- Dry powder inhalers can deliver SABA in mild-moderate exacerbations but not for severe acute asthma.
- For life-threatening asthma in primary care, give SABA, ipratropium, systemic corticosteroids, and oxygen while arranging transfer.
The document provides an overview of the Global Initiative for Asthma's 2019 strategy for asthma management and prevention. It discusses GINA's goals of reducing asthma prevalence, morbidity, and mortality. It also summarizes the key aspects of asthma including phenotypes, diagnosis, assessment of control and risk factors, and pharmacological and non-pharmacological treatment strategies. The treatment approach involves classifying asthma severity and control to determine the appropriate controller medications and adjusting the treatment regimen up or down as needed.
This document discusses guidelines from the Global Initiative for Asthma (GINA) for defining, describing, diagnosing and treating asthma. It provides definitions of asthma as a chronic inflammatory disease of the airways characterized by variable respiratory symptoms. It outlines the criteria for diagnosing asthma based on symptoms, lung function tests and response to treatment. It also discusses evaluating asthma control and severity, and establishing a treatment plan to control symptoms and reduce risks. The goal of treatment is to achieve good symptom control and maintain normal daily activity levels while decreasing risks of exacerbations and adverse effects.
GINA 2019: a fundamental change in asthma management Ashraf ElAdawy
Mild asthma accounts for 50-75% of the asthma population. While symptoms may be infrequent or mild, airway inflammation is still present and patients are at risk of exacerbations. Recent guidelines recommend low-dose inhaled corticosteroids as the preferred first-line treatment for mild asthma over short-acting beta agonists alone due to safety concerns around overreliance on reliever medications and risk of exacerbations. New studies provide evidence that symptom-driven use of combination inhalers containing an inhaled corticosteroid and long-acting beta agonist may be effective alternatives to regular maintenance treatment for mild asthma.
The document summarizes the Global Initiative for Asthma's 2019 strategy for managing asthma. It outlines that asthma is a heterogeneous disease characterized by chronic airway inflammation. It then discusses asthma phenotypes, diagnosis of asthma, assessing asthma control and risk factors, and treatment options. The treatment approach involves a stepwise approach starting with low dose inhaled corticosteroids and adding additional controllers as needed to control symptoms and reduce exacerbation risk. The 2019 update emphasizes adding inhaled corticosteroids for all patients rather than short-acting bronchodilators alone due to risks of exacerbations from the latter approach.
This document provides recommendations from the British guideline on the management of asthma. It recommends that the initial assessment of asthma in both children and adults should focus on taking a thorough clinical history and considering alternative diagnoses. For those with a high probability of asthma, treatment should be started, while further testing is reserved for poor responders. For intermediate probability cases, tests like lung function and a treatment trial can help determine if a diagnosis of asthma is appropriate. Self-management education and written asthma action plans are recommended to improve health outcomes.
Dr. Kumar Utsav presented an update on the Global Initiative for Asthma (GINA) 2017 guidelines. Key changes included adding sublingual immunotherapy as an add-on option for some patients, updating recommendations for severe asthma treatment including new biologics, and clarifying the use of fractional exhaled nitric oxide testing in diagnosis and management. The guidelines emphasize a practical clinical approach for managing asthma in both high and low-resource settings.
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.
The document summarizes a clinical trial that compared the effectiveness of adding montelukast (Singulair) versus salmeterol/fluticasone (Advair) or increasing the dose of fluticasone for children with uncontrolled asthma on low-dose inhaled corticosteroids. The BADGER trial found that adding salmeterol to fluticasone or increasing the fluticasone dose resulted in better asthma control compared to adding montelukast. However, some children responded better to montelukast. The document concludes that while several options exist, the patient's current level of control indicates a need to step up therapy beyond low-dose inhaled corticosteroids alone
This document provides an overview of acute asthma and recent evidence-based guidelines. It discusses the pathophysiology of asthma and clinical presentation. Updated guidelines from NAEPP, GINA, and ERS/ATS are presented which classify asthma severity and provide stepwise recommendations for pharmacological management. Key points include distinguishing between severe versus uncontrolled asthma, evaluating for treatment non-adherence and comorbidities before diagnosing severe asthma, and emphasizing environmental control and inhaler technique.
Serum magnesium level in children with bronchial asthma Azad Haleem
- The study aimed to determine the prevalence of hypomagnesemia (low magnesium levels) among asthmatic children compared to healthy controls.
- The mean serum magnesium level was found to be significantly lower in asthmatic children (1.91 mg/dL) than in healthy controls (2.03 mg/dL).
- Within the asthmatic group, serum magnesium levels decreased with increased asthma severity and inversely correlated with duration of asthma, though not significantly.
- The study concluded that asthmatic children have higher risk of magnesium deficiency and supplementation may help improve asthma outcomes.
this guideline based on recent articles by major education establishments concerned with building national guidelines. please dont be hurry to make comments about use of IV aminophylline. aminiphylline used under some extra care and when other treatment options are failing. benefits of those treatments yet remain controversial. IV aminophylline has its own risks including the possibility of toxicity.
This document discusses asthma in children and provides guidelines for diagnosis and management. It notes that most childhood asthma starts in the preschool years and can be classified into different phenotypes based on risk factors and symptoms. The goals of treatment are to control symptoms and prevent exacerbations. Spirometry can help diagnose and monitor asthma in children over 6 years old, while other tools like peak flow meters and exhaled nitric oxide can help in younger children. Treatment involves a stepwise approach starting with reliever medications and adding controller medications like inhaled corticosteroids based on symptom severity and risk of exacerbations. Close monitoring is important to maintain control and reduce medication doses if possible.
The document discusses the need for a refresher course on obstructive airways diseases (OAD) in India. It notes that OADs such as asthma and COPD represent a major health burden in India, with prevalence increasing. However, a large number of OAD cases remain undiagnosed due to underuse of spirometry testing and poor management of patients in clinical practice. Inhaler therapy is also not widely used properly. A refresher course could help address these issues to improve diagnosis and management of OADs in India.
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.
Este documento presenta información sobre las nuevas recomendaciones del GINA 2014 para el diagnóstico y tratamiento del asma. En 3 oraciones o menos:
1) El GINA busca aumentar la conciencia sobre el asma como problema de salud global, presentar recomendaciones clave para el diagnóstico y tratamiento, y proveer estrategias para adaptar las recomendaciones a diferentes contextos. 2) El documento describe los criterios para diagnosticar asma basados en síntomas e historia del paciente, así como pruebas objetivas como la reversibilidad del flu
Global copd and asthma devices market (product types and geography) forecast ...Allied Market Research
The COPD and Asthma hold the largest market share within the global respiratory diseases’ market. As estimated by Global Initiative for Asthma (GINA), approximately 300 million people suffer from Asthma globally.
The document provides guidelines for the acute management of asthma exacerbations, including risk factors, classifications of exacerbation severity from mild to life-threatening, and treatment protocols based on peak expiratory flow rate and clinical presentation. It also covers discharge planning and the use of peak expiratory flow monitoring to assess asthma control and exacerbation risk.
This document discusses paediatric asthma management from theory to clinical practice. It provides an overview of childhood asthma as a global health issue, outlines factors influencing prevalence, and discusses the burden of childhood asthma. It also covers evaluating asthma control, Global Initiative for Asthma treatment guidelines, and strategies for maintaining control or stepping up treatment in response to loss of control. Key studies comparing inhaled versus oral therapies and the efficacy of different controller medications are summarized.
This document provides an overview of asthma, including its definition, pathogenesis, diagnosis, classification of severity, management, and monitoring. Some key points:
- Asthma is a chronic inflammatory airway disease characterized by airway hyperresponsiveness and reversible airflow obstruction. It affects approximately 7% of the global population.
- Diagnosis is based on a clinical history of recurrent wheezing, coughing, chest tightness and breathlessness, and confirmation via pulmonary function tests showing obstruction and reversibility.
- Asthma severity is classified as mild, moderate or severe based on symptom frequency and lung function. Treatment involves inhaled corticosteroids with additional controllers as needed.
- Patient education on self-
This document discusses asthma in pregnancy. It defines asthma as a chronic inflammatory disease of the airways characterized by variable airflow limitation and respiratory symptoms. The prevalence of asthma in pregnancy ranges from 1-4%. The document outlines the risks of uncontrolled asthma in pregnancy, including preeclampsia, preterm birth, and low birth weight. It also covers the pathophysiology of asthma and how pregnancy affects respiratory physiology. Examination findings, differential diagnoses, diagnostic tests, treatment options, and management of asthma during pregnancy are discussed in detail.
Asthma. Self study materials for medical students. (In collaboration with Zhu...Anton Litvin
Asthma. Self study materials for medical students.
Prepared in co-authorship with my dear colleague MD Zhuravka Natalia, assistant proffesor of Internal Medicine department, V.N. Karazin University.
El documento resume la crisis asmática, definiéndola como un episodio agudo o subagudo caracterizado por un aumento de síntomas como disnea, tos y sibilancias junto con una disminución de los flujos espiratorios. Explica la fisiopatología, etiología, clasificación, diagnóstico y tratamiento de la crisis asmática según la Guía GINA 2015. El documento proporciona información sobre la epidemiología, tipos de asma, factores desencadenantes, signos y síntomas, pruebas para establecer
Intussusception is the invagination of one part of the intestine into another. It most commonly occurs in infants and children between 6 months and 2 years of age. Ultrasound is the preferred method of diagnosis as it can clearly visualize the "coiled-spring" or "bull's-eye" pattern of intussusception. Non-operative reduction using hydrostatic or pneumatic enema under fluoroscopic or ultrasound guidance is the first-line treatment and has high success rates of 80-95%. Surgical intervention is needed if non-operative reduction fails or if there is evidence of intestinal ischemia or perforation.
incidence and prevalence of asthma in pregnancy, guidelines for diagnosis and management of during pregnancy. drugs to be given and drugs to be avoided during pregnancy. pregnancy outcome in asthma patients.
This document discusses asthma, including its pathogenesis, triggers, symptoms, diagnosis and classification. It notes that asthma is a chronic inflammatory airway disease characterized by reversible bronchial constriction in response to multiple stimuli. Common symptoms include dyspnea, cough and wheezing. Diagnosis involves assessing symptoms, demonstrating reversibility of airflow obstruction via spirometry, and ruling out alternative diagnoses. Asthma is classified based on severity of symptoms and lung function.
This document provides guidelines for patient admission and management in the labour ward of Sarawak General Hospital. [1] It outlines procedures for triaging and admitting patients through the labour ward, prioritizing emergency cases. [2] It describes standards for assessing patients, providing information to patients and families, and following protocols to ensure safety during delivery and postpartum care. [3] Specific guidelines are given for managing high-risk deliveries and transferring babies that require neonatal intensive care.
- Asthma is characterized by airway inflammation and constriction caused by various triggers that vary between individuals. Common triggers include allergens, viruses, smoke, and exercise.
- The course of asthma during pregnancy is unpredictable, with symptoms improving in some, worsening in others, and no change in the remaining third. Poorly controlled asthma is associated with increased risks for complications.
- Most asthma medications are considered low risk during pregnancy and breastfeeding. Corticosteroids should not be withheld due to safety concerns. Acute asthma attacks during pregnancy require prompt treatment including oxygen, fluids, bronchodilators, and corticosteroids.
1. The document discusses guidelines from the Global Initiative for Asthma (GINA) for diagnosing and managing asthma.
2. Asthma is defined as a chronic inflammatory disease characterized by variable respiratory symptoms and airflow limitation. It affects 300 million people worldwide.
3. GINA recommends a stepwise approach to asthma treatment based on symptom control and exacerbation risk. Treatment includes inhaled corticosteroids, long-acting beta-agonists, and leukotriene modifiers. The goal is to control symptoms and reduce future risk.
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 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 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.
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 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 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.
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.
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.
The document discusses the use of corticosteroids in treating several respiratory conditions, including acute severe asthma, acute exacerbation of COPD, and acute respiratory distress syndrome. It provides definitions and prevalence data for these conditions. Guidelines are presented for using corticosteroids to treat exacerbations, including recommendations from GINA and AAFP. A study is summarized that found intravenous methylprednisolone followed by oral methylprednisolone was more effective and safer than intravenous hydrocortisone followed by oral prednisolone for treating acute asthma exacerbations.
Guides for asthma management and prevention for children 5 and younger(be a g...Hussain Okairy
This document provides guidance for healthcare professionals on diagnosing and managing asthma in children aged 5 years and younger. Asthma is common in childhood, but can be difficult to diagnose in young children due to frequent wheezing from other causes. The diagnosis is based on recurrent symptoms like wheezing and cough in response to triggers. Treatment follows a stepwise approach starting with education and environmental control, and adding low-dose inhaled corticosteroids as needed to control symptoms and prevent exacerbations. Acute exacerbations should be treated promptly at home or in primary care to avoid hospitalization.
This document provides guidelines for the global management and prevention of asthma. It summarizes the burden of asthma, factors that influence asthma development and expression, mechanisms of asthma including airway inflammation and pathophysiology. It also outlines recommendations for diagnosing and classifying asthma, as well as treating asthma with medications. The treatment section provides guidance on controller and reliever medications for both adults and children. Additionally, it describes components of asthma management and prevention, including developing patient-doctor partnerships, identifying and reducing risk factors, assessing and monitoring asthma control, managing exacerbations, and special considerations.
This document provides a 3-sentence summary of the given document:
The document is the 2012 updated Global Strategy for Asthma Management and Prevention report published by the Global Initiative for Asthma (GINA). It outlines recommendations for diagnosing and classifying asthma, as well as treating asthma with medications and managing asthma prevention. The report was updated by the GINA Board of Directors and Science Committee, which include asthma experts from around the world.
This document provides a 3-sentence summary of the Global Strategy for Asthma Management and Prevention 2012 report:
The report is authored by an international board and committee and provides updated clinical recommendations for diagnosing and managing asthma based on assessing, treating, and maintaining asthma control. It describes factors that influence asthma such as genetics, environment, and lifestyle, and covers approaches to developing partnerships with patients, identifying and reducing risk factors, treating asthma with different medication types and delivery methods, and managing exacerbations. The report is intended to help health care professionals provide effective and individualized care for people with asthma globally.
CUAL ES L PREVALENCIA E INCIDENCIA DE LA PATOLOGIA RESPIRATORIACarlosChavarry1
This document summarizes a case study of a 70-year-old man referred for shortness of breath and nasal allergy symptoms. His medical history included coronary artery disease, gastroesophageal reflux disease, and a smoking history. Initial testing showed improvement in lung function with bronchodilation, and allergy testing was positive. He was diagnosed with asthma and started on inhaled corticosteroids and bronchodilators, which improved his symptoms. Over subsequent visits, his medications were adjusted and lung function continued to improve. The document discusses challenges in diagnosing asthma in older adults and evaluating for alternative causes, and emphasizes using a detailed history, physical exam, objective testing, and trial of treatment to establish a diagnosis.
This document summarizes the key updates to the 2021 Global Initiative for Asthma (GINA) strategy report. It discusses that GINA now recommends against using short-acting beta-agonists (SABAs) alone for mild asthma and that all adults and adolescents should receive inhaled corticosteroid (ICS)-containing controller treatment. It reviews evidence that using ICS-formoterol as both maintenance and reliever therapy reduces exacerbation risk compared to SABA reliever therapy. The document outlines GINA's new preferred dual maintenance and reliever treatment approach for adults and adolescents with asthma.
- Asthma is a chronic inflammatory disease of the airways characterized by airway hyperresponsiveness and reversible bronchospasm.
- It most commonly begins in childhood, with over 77% of cases presenting before 5 years of age. Diagnosis can be challenging in young children due to their inability to perform pulmonary function tests.
- Treatment involves inhalation of corticosteroids and bronchodilators. Short courses of oral corticosteroids are used for acute exacerbations. Patient education is important for proper inhaler technique and trigger avoidance.
- Asthma is a common incurable disease that affects the airways, causing them to narrow. It is more common in childhood but can occur at any age.
- In the UK, asthma is primarily managed by general practitioners and nurses in primary, secondary, and tertiary care settings depending on severity. Specialist nurses play an important role in asthma management and education.
- Proper asthma management involving reliever inhalers, treatment plans, and trigger avoidance can help control symptoms and reduce emergency admissions. Leadership and management skills are important for nurses to effectively guide patients.
Dr Mike Bromley talks about the role of Manchester University in the research and development of new antifungal drugs, followed by Dr Iain Page talking about our research projects in Africa that have the potential to reveal much larger numbers of people suffering from Chronic Pulmonary Aspergillosis (CPA) than is currently thought.
Mental Health and well-being Presentation. Exploring innovative approaches and strategies for enhancing mental well-being. Discover cutting-edge research, effective strategies, and practical methods for fostering mental well-being.
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Microstomia, characterized by an abnormally small oral aperture, presents significant challenges in prosthodontic treatment, including limited access for examination, difficulties in impression making, and challenges with prosthesis insertion and removal. To manage these issues, customized impression techniques using sectional trays and elastomeric materials are employed. Prostheses may be designed in segments or with flexible materials to facilitate handling. Minimally invasive procedures and the use of digital technologies can enhance patient comfort. Education and training for patients on prosthesis care and maintenance are crucial for compliance. Regular follow-up and a multidisciplinary approach, involving collaboration with other specialists, ensure comprehensive care and improved quality of life for microstomia patients.
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COLOUR CODING IN THE PERIOPERATIVE ENVIRONMENT HAS COME TO STAY ,SOME SENCE OF HUMOUR WILL BE APPRECIATED AT THE RIGHT TIME BY THE PATIENT AND OTHER SURGICAL TEAM MEMBERS.
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TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - ...rightmanforbloodline
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - 34.
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NURSING MANAGEMENT OF PATIENT WITH EMPHYSEMA .PPTblessyjannu21
Prepared by Prof. BLESSY THOMAS, VICE PRINCIPAL, FNCON, SPN.
Emphysema is a disease condition of respiratory system.
Emphysema is an abnormal permanent enlargement of the air spaces distal to terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis.
Emphysema of lung is defined as hyper inflation of the lung ais spaces due to obstruction of non respiratory bronchioles as due to loss of elasticity of alveoli.
It is a type of chronic obstructive
pulmonary disease.
It is a progressive disease of lungs.
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2. 1
GLOBAL INITIATIVE
FOR ASTHMA
POCKET GUIDE FOR HEALTH PROFESSIONALS
Updated 2016
GINA Board of Directors
Chair: J Mark FitzGerald, MD
GINA Science Committee
Chair: Helen Reddel, MBBS PhD
GINA Dissemination and Implementation Committee
Chair: Louis-Philippe Boulet, MD
GINA Assembly
The GINA Assembly includes members from 45 countries, listed on the
GINA website www.ginasthma.org.
GINA Program
Suzanne Hurd, PhD (to Dec 2015); Rebecca Decker, BS, MSJ
Names of members of the GINA Committees are listed on page 28.
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3. 2
TABLE OF CONTENTS
Preface ............................................................................................................3
What is known about asthma?.........................................................................4
Making the diagnosis of asthma ......................................................................5
Criteria for making the diagnosis of asthma................................................6
Diagnosing asthma in special populations ..................................................7
Assessing a patient with asthma......................................................................8
How to assess asthma control ....................................................................9
How to investigate uncontrolled asthma....................................................10
Management of asthma .................................................................................11
General principles .....................................................................................11
Treating to control symptoms and minimize risk .......................................11
Control-based asthma management.........................................................12
Initial controller treatment..........................................................................13
Stepwise approach for adjusting treatment...............................................16
Reviewing response and adjusting treatment ...........................................17
Inhaler skills and adherence .....................................................................18
Treating modifiable risk factors .................................................................19
Non-pharmacological strategies and interventions ...................................19
Treatment in special populations or contexts............................................20
Asthma flare-ups (exacerbations)..................................................................21
Written asthma action plans......................................................................22
Managing exacerbations in primary or acute care ....................................23
Reviewing response..................................................................................23
Follow-up after an exacerbation................................................................25
Glossary of asthma medication classes.........................................................26
Acknowledgements........................................................................................28
GINA publications..........................................................................................28
TABLE OF FIGURES
Box 1. Diagnostic flow-chart for asthma in clinical practice...........................5
Box 2. Features used in making the diagnosis of asthma.............................6
Box 3. How to assess a patient with asthma.................................................8
Box 4. Assessment of symptom control and future risk ................................9
Box 5. How to investigate uncontrolled asthma in primary care..................10
Box 6. The control-based asthma management cycle ................................12
Box 7. Stepwise approach to asthma treatment .........................................14
Box 8. Low, medium and high daily doses of inhaled corticosteroids .........14
Box 9. Self-management with a written action plan ....................................22
Box 10. Management of asthma exacerbations in primary care ...................24
Abbreviations used in this Pocket Guide are found on page 27.
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4. 3
PREFACE
Asthma affects an estimated 300 million individuals worldwide. It is a serious
global health problem affecting all age groups, with increasing prevalence in
many developing countries, rising treatment costs, and a rising burden for
patients and the community. Asthma still imposes an unacceptable burden on
health care systems, and on society through loss of productivity in the
workplace and, especially for pediatric asthma, disruption to the family.
Health care providers managing asthma face different issues around the
world, depending on the local context, the health system, and access to
resources.
The Global Initiative for Asthma (GINA) was established to increase
awareness about asthma among health professionals, public health
authorities and the community, and to improve prevention and management
through a coordinated worldwide effort. GINA prepares scientific reports on
asthma, encourages dissemination and implementation of the
recommendations, and promotes international collaboration on asthma
research.
The Global Strategy for Asthma Management and Prevention was
extensively revised in 2014 to provide a comprehensive and integrated
approach to asthma management that can be adapted for local conditions
and for individual patients. It focuses not only on the existing strong evidence
base, but also on clarity of language and on providing tools for feasible
implementation in clinical practice. The report has been updated each year
since then.
The GINA 2016 report and other GINA publications listed on page 28 can be
obtained from www.ginasthma.org.
The reader acknowledges that this Pocket Guide is a brief summary of the
GINA 2016 report for primary health care providers. It does NOT contain all of
the information required for managing asthma, for example, about safety of
treatments, and it should be used in conjunction with the full GINA 2016
report and with the health professional’s own clinical judgment. GINA cannot
be held liable or responsible for healthcare administered with the use of this
document, including any use which is not in accordance with applicable local
or national regulations or guidelines.
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5. 4
WHAT IS KNOWN ABOUT ASTHMA?
Asthma is a common and potentially serious chronic disease that
imposes a substantial burden on patients, their families and the community. It
causes respiratory symptoms, limitation of activity, and flare-ups (attacks) that
sometimes require urgent health care and may be fatal.
Fortunately…asthma can be effectively treated, and most patients can
achieve good control of their asthma. When asthma is under good control,
patients can:
Avoid troublesome symptoms during day and night
Need little or no reliever medication
Have productive, physically active lives
Have normal or near normal lung function
Avoid serious asthma flare-ups (exacerbations, or attacks)
What is asthma? Asthma causes symptoms such as wheezing, shortness of
breath, chest tightness and cough that vary over time in their occurrence,
frequency and intensity.
These symptoms are associated with variable expiratory airflow, i.e. difficulty
breathing air out of the lungs due to bronchoconstriction (airway narrowing),
airway wall thickening, and increased mucus. Some variation in airflow can
also occur in people without asthma, but it is greater in asthma.
Factors that may trigger or worsen asthma symptoms include viral
infections, domestic or occupational allergens (e.g. house dust mite, pollens,
cockroach), tobacco smoke, exercise and stress. These responses are more
likely when asthma is uncontrolled. Some drugs can induce or trigger asthma,
e.g. beta-blockers, and (in some patients), aspirin or other NSAIDs.
Asthma flare-ups (also called exacerbations or attacks) may occur even in
people taking asthma treatment. When asthma is uncontrolled, or in some
high-risk patients, these episodes are more frequent and more severe, and
may be fatal.
A stepwise approach to treatment, customized to the individual patient,
takes into account the effectiveness of available medications, their safety, and
their cost to the payer or patient.
Regular controller treatment, particularly with inhaled corticosteroid (ICS)-
containing medications, markedly reduces the frequency and severity of
asthma symptoms and the risk of having a flare-up.
Asthma is a common condition, affecting all levels of society. Olympic
athletes, famous leaders and celebrities, and ordinary people live successful
and active lives with asthma.
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6. 5
MAKING THE DIAGNOSIS OF ASTHMA
Asthma is a disease with many variations (heterogeneous), usually
characterized by chronic airway inflammation. Asthma has two key defining
features:
• a history of respiratory symptoms such as wheeze, shortness of breath,
chest tightness and cough that vary over time and in intensity, AND
• variable expiratory airflow limitation.
A flow-chart for making the diagnosis in clinical practice is shown in Box 1,
with the specific criteria for diagnosing asthma in Box 2.
Box 1. Diagnostic flow-chart for asthma in clinical practice
The diagnosis of asthma should be confirmed and, for future reference, the
evidence documented in the patient’s notes. Depending on clinical urgency
and access to resources, this should preferably be done before starting
controller treatment. Confirming the diagnosis of asthma is more difficult after
treatment has been started (see p7).
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7. 6
CRITERIA FOR MAKING THE DIAGNOSIS OF ASTHMA
Box 2. Features used in making the diagnosis of asthma
1. A history of variable respiratory symptoms
Typical symptoms are wheeze, shortness of breath, chest tightness, cough
• People with asthma generally have more than one of these symptoms
• The symptoms occur variably over time and vary in intensity
• The symptoms often occur or are worse at night or on waking
• Symptoms are often triggered by exercise, laughter, allergens or cold air
• Symptoms often occur with or worsen with viral infections
2. Evidence of variable expiratory airflow limitation
• At least once during the diagnostic process when FEV1 is low,
document that the FEV1/FVC ratio is reduced. The FEV1/FVC ratio is
normally more than 0.75–0.80 in adults, and more than 0.90 in children.
• Document that variation in lung function is greater than in healthy
people. For example:
o FEV1 increases by more than 12% and 200mL (in children, >12%
of the predicted value) after inhaling a bronchodilator. This is
called ‘bronchodilator reversibility’.
o Average daily diurnal PEF variability* is >10% (in children, >13%)
o FEV1 increases by more than 12% and 200mL from baseline (in
children, by >12% of the predicted value) after 4 weeks of anti-
inflammatory treatment (outside respiratory infections)
• The greater the variation, or the more times excess variation is seen,
the more confident you can be of the diagnosis
• Testing may need to be repeated during symptoms, in the early
morning, or after withholding bronchodilator medications.
• Bronchodilator reversibility may be absent during severe exacerbations
or viral infections. If bronchodilator reversibility is not present when it is
first tested, the next step depends on the clinical urgency and
availability of other tests.
• For other tests to assist in diagnosis, including bronchial challenge
tests, see Chapter 1 of the GINA 2016 report.
*Calculated from twice daily readings (best of 3 each time), as (the day’s highest PEF
minus the day’s lowest PEF) divided by the mean of the day’s highest and lowest PEF,
and averaged over 1-2 weeks. If using PEF at home or in the office, use the same PEF
meter each time.
Physical examination in people with asthma is often normal, but the most
frequent finding is wheezing on auscultation, especially on forced expiration.
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8. 7
DIAGNOSING ASTHMA IN SPECIAL POPULATIONS
Patients with cough as the only respiratory symptom
This may be due to chronic upper airway cough syndrome (‘post-nasal drip’),
chronic sinusitis, gastroesophageal reflux (GERD), vocal cord dysfunction, or
eosinophilic bronchitis, or cough variant asthma. Cough variant asthma is
characterized by cough and airway hyperresponsiveness, and documenting
variability in lung function is essential to make this diagnosis. However, lack of
variability at the time of testing does not exclude asthma. For other diagnostic
tests, see Box 2, and Chapter 1 of the GINA 2016 report, or refer the patient
for specialist opinion.
Occupational asthma and work-aggravated asthma
Every patient with adult-onset asthma should be asked about occupational
exposures, and whether their asthma is better when they are away from work.
It is important to confirm the diagnosis objectively (which often needs
specialist referral) and to eliminate exposure as soon as possible.
Pregnant women
Ask all pregnant women and those planning pregnancy about asthma, and
advise them about the importance of asthma treatment for the health of both
mother and baby.
The elderly
Asthma may be under-diagnosed in the elderly, due to poor perception, an
assumption that dyspnea is normal in old age, lack of fitness, or reduced
activity. Asthma may also be over-diagnosed in the elderly through confusion
with shortness of breath due to left ventricular failure or ischemic heart
disease. If there is a history of smoking or biomass fuel exposure, COPD or
asthma-COPD overlap syndrome (ACOS) should be considered (see Chapter
5 of the GINA 2016 report).
Smokers and ex-smokers
Asthma and COPD may co-exist or overlap (asthma-COPD overlap
syndrome, ACOS), particularly in smokers and the elderly. The history and
pattern of symptoms and past records can help to distinguish asthma with
fixed airflow limitation from COPD. Uncertainty in diagnosis should prompt
early referral, as ACOS has worse outcomes than asthma or COPD alone.
Confirming an asthma diagnosis in patients taking controller treatment:
For many patients (25–35%) with a diagnosis of asthma in primary care, the
diagnosis cannot be confirmed. If the basis of the diagnosis has not already
been documented, confirmation with objective testing should be sought.
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9. 8
If standard criteria for asthma (Box 2) are not met, consider other
investigations. For example, if lung function is normal, repeat reversibility
testing after withholding medications for 12 hours. If the patient has frequent
symptoms, consider a trial of step-up in controller treatment and repeat lung
function testing after 3 months. If the patient has few symptoms, consider
stepping down controller treatment, but ensure the patient has a written
asthma action plan, monitor them carefully, and repeat lung function testing.
ASSESSING A PATIENT WITH ASTHMA
Take every opportunity to assess patients with a diagnosis of asthma,
particularly when they are symptomatic or after a recent exacerbation, but
also when they ask for a prescription refill. In addition, schedule a routine
review at least once a year.
Box 3. How to assess a patient with asthma
1. Asthma control – assess both symptom control and risk factors
• Assess symptom control over the last 4 weeks (Box 4, p9)
• Identify any other risk factors for poor outcomes (Box 4)
• Measure lung function before starting treatment, 3–6 months later, and
then periodically, e.g. yearly
2. Treatment issues
• Record the patient’s treatment (Box 7, p14), and ask about side-effects
• Watch the patient using their inhaler, to check their technique (p18)
• Have an open empathic discussion about adherence (p18)
• Check that the patient has a written asthma action plan (p22)
• Ask the patient about their attitudes and goals for their asthma
3. Are there any comorbidities?
• These include rhinitis, rhinosinusitis, gastroesophageal reflux (GERD),
obesity, obstructive sleep apnea, depression and anxiety.
• Comorbidities should be identified as they may contribute to respiratory
symptoms and poor quality of life. Their treatment may complicate
asthma management.
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10. 9
HOW TO ASSESS ASTHMA CONTROL
Asthma control means the extent to which the effects of asthma can be seen
in the patient, or have been reduced or removed by treatment. Asthma control
has two domains: symptom control (previously called ‘current clinical control’)
and risk factors for future poor outcomes.
Poor symptom control is a burden to patients and a risk factor for flare-ups.
Risk factors are factors that increase the patient’s future risk of having
exacerbations (flare-ups), loss of lung function, or medication side-effects.
Box 4. Assessment of symptom control and future risk
A. Level of asthma symptom control
In the past 4 weeks, has the patient had: Well
controlled
Partly
controlled
Uncontrolled
Daytime symptoms more than twice/week? Yes No
None
of these
1–2
of these
3–4
of these
Any night waking due to asthma? Yes No
Reliever needed* more than twice/week? Yes No
Any activity limitation due to asthma? Yes No
B. Risk factors for poor asthma outcomes
Assess risk factors at diagnosis and periodically, particularly for patients experiencing
exacerbations.
Measure FEV1 at start of treatment, after 3–6 months of controller treatment to record
personal best lung function, then periodically for ongoing risk assessment.
Potentially modifiable independent risk factors for exacerbations include:
• Uncontrolled asthma symptoms (as above)
• ICS not prescribed; poor ICS adherence; incorrect inhaler technique
• High SABA use (with increased mortality if >1x200-dose canister/month)
• Low FEV1, especially if <60% predicted
• Major psychological or socioeconomic problems
• Exposures: smoking; allergen exposure if sensitized
• Comorbidities: obesity; rhinosinusitis; confirmed food allergy
• Sputum or blood eosinophilia
• Pregnancy
Other major independent risk factors for flare-ups (exacerbations) include:
• Ever being intubated or in intensive care for asthma
• Having 1 or more severe exacerbations in the last 12 months.
Risk factors for developing fixed airflow limitation include lack of ICS treatment; exposure to tobacco
smoke, noxious chemicals or occupational exposures; low FEV1; chronic mucus hypersecretion; and
sputum or blood eosinophilia
Risk factors for medication side-effects include:
• Systemic: frequent OCS; long-term, high dose and/or potent ICS; also taking P450 inhibitors
• Local: high-dose or potent ICS; poor inhaler technique
Having one or more
of these risk factors
increases the risk of
exacerbations even
if symptoms are well
controlled.
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11. 10
What is the role of lung function in monitoring asthma?
Once asthma has been diagnosed, lung function is most useful as an
indicator of future risk. It should be recorded at diagnosis, 3–6 months after
starting treatment, and periodically thereafter. Patients who have either few or
many symptoms relative to their lung function need more investigation.
How is asthma severity assessed?
Asthma severity can be assessed retrospectively from the level of treatment
(p14) required to control symptoms and exacerbations. Mild asthma is asthma
that can be controlled with Step 1 or 2 treatment. Severe asthma is asthma
that requires Step 4 or 5 treatment, to maintain symptom control. It may
appear similar to asthma that is uncontrolled due to lack of treatment.
HOW TO INVESTIGATE UNCONTROLLED ASTHMA
Most patients can achieve good asthma control with regular controller
treatment, but some patients do not, and further investigation is needed.
Box 5. How to investigate uncontrolled asthma in primary care
This flow-chart shows the most common problems first, but the steps can be
carried out in a different order, depending on resources and clinical context.
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12. 11
MANAGEMENT OF ASTHMA
GENERAL PRINCIPLES
The long-term goals of asthma management are symptom control and
risk reduction. The aim is to reduce the burden to the patient and their risk of
exacerbations, airway damage, and medication side-effects. The patient’s
own goals regarding their asthma and its treatment should also be identified.
Population-level recommendations about ‘preferred’ asthma treatments
represent the best treatment for most patients in a population.
Patient-level treatment decisions should take into account any individual
characteristics or phenotype that predict the patient’s likely response to
treatment, together with the patient’s preferences and practical issues such as
inhaler technique, adherence, and cost.
A partnership between the patient and their health care providers is
important for effective asthma management. Training health care providers in
communication skills may lead to increased patient satisfaction, better
health outcomes, and reduced use of health care resources.
Health literacy – that is, the patient’s ability to obtain, process and
understand basic health information to make appropriate health decisions –
should be taken into account in asthma management and education.
TREATING TO CONTROL SYMPTOMS AND MINIMIZE RISK
Treatment of asthma for symptom control and risk reduction includes:
• Medications. Every patient with asthma should have a reliever
medication, and most adults and adolescents with asthma should have a
controller medication
• Treating modifiable risk factors
• Non-pharmacological therapies and strategies
Importantly, every patient should also be trained in essential skills and guided
asthma self-management, including:
• Asthma information
• Inhaler skills (p18)
• Adherence (p18)
• Written asthma action plan (p22)
• Self-monitoring
• Regular medical review (p8)
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13. 12
CONTROL-BASED ASTHMA MANAGEMENT
Asthma treatment is adjusted in a continuous cycle to assess, adjust
treatment and review response. The main components of this cycle are
shown in Box 6.
Box 6. The control-based asthma management cycle
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14. 13
INITIAL CONTROLLER TREATMENT
For the best outcomes, regular daily controller treatment should be initiated as
soon as possible after the diagnosis of asthma is made, because:
• Early treatment with low dose ICS leads to better lung function than if
symptoms have been present for more than 2–4 years
• Patients not taking ICS who experience a severe exacerbation have
lower long-term lung function than those who have started ICS
• In occupational asthma, early removal from exposure and early treatment
increase the probability of recovery
Regular low dose ICS is recommended for patients with any of the
following:
• Asthma symptoms more than twice a month
• Waking due to asthma more than once a month
• Any asthma symptoms plus any risk factor(s) for exacerbations
(e.g. needing OCS for asthma within the last 12 months; low FEV1; ever
in intensive care unit for asthma)
Consider starting at a higher step (e.g. medium/high dose ICS, or ICS/LABA)
if the patient has troublesome asthma symptoms on most days; or is waking
from asthma once or more a week, especially if there are any risk factors for
exacerbations.
If the initial asthma presentation is with severely uncontrolled asthma, or with
an acute exacerbation, give a short course of OCS and start regular controller
treatment (e.g. high dose ICS, or medium dose ICS/LABA).
Low, medium and high dose categories for different ICS medications are
shown in Box 8 (p14).
Before starting initial controller treatment
• Record evidence for the diagnosis of asthma, if possible
• Document symptom control and risk factors
• Assess lung function, when possible
• Train the patient to use the inhaler correctly, and check their technique
• Schedule a follow-up visit
After starting initial controller treatment
• Review response after 2–3 months, or according to clinical urgency
• See Box 7 for ongoing treatment and other key management issues
• Consider step down when asthma has been well-controlled for 3 months
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15. Box 7. Stepwise approach to asthma treatment
*Not for children <12 years. **For children 6–11 years, the preferred Step 3 treatment is medium dose ICS. # Low dose ICS/formoterol is the
reliever medication for patients prescribed low dose budesonide/formoterol or low dose beclometasone/formoterol for maintenance and reliever
therapy. Tiotropium by mist inhaler is an add-on treatment for patients with a history of exacerbations*.
For medication Glossary, see p26. For details about treatment recommendations, supporting evidence, and clinical advice about
implementation in different populations see the full GINA 2016 report (www.ginasthma.org).
Box 8. Low, medium and high daily doses of inhaled corticosteroids (mcg)
Inhaled corticosteroid Adults and adolescents Children 6–11 years
Low Medium High Low Medium High
Beclometasone dipropionate (CFC)* 200–500 >500–1000 >1000 100–200 >200–400 >400
Beclometasone dipropionate (HFA) 100–200 >200–400 >400 50-100 >100-200 >200
Budesonide (DPI) 200–400 >400–800 >800 100–200 >200–400 >400
Budesonide (nebules) 250–500 >500–1000 >1000
Ciclesonide (HFA) 80–160 >160–320 >320 80 >80-160 >160
Fluticasone furoate (DPI) 100 n.a. 200 n.a. n.a. n.a.
Fluticasone propionate( DPI) 100–250 >250–500 >500 100–200 >200–400 >400
Fluticasone propionate (HFA) 100–250 >250–500 >500 100–200 >200–500 >500
Mometasone furoate 110–220 >220–440 >440 110 ≥220–<440 ≥440
Triamcinolone acetonide 400–1000 >1000–2000 >2000 400–800 >800–1200 >1200
CFC: chlorofluorocarbon propellant; DPI: dry powder inhaler; HFA: hydrofluoroalkane propellant. *Included for comparison with older literature.
15
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16. 16
STEPWISE APPROACH FOR ADJUSTING TREATMENT
Once asthma treatment has been started, ongoing decisions are based on a
cycle to assess, adjust treatment and review response. The preferred
treatments at each step are summarized below and in Box 7 (p14); for details,
see full GINA 2016 report. See Box 8 (p14) for ICS dose categories.
STEP 1: As-needed SABA with no controller (this is indicated only if
symptoms are rare, there is no night waking due to asthma, no
exacerbations in the last year, and normal FEV1).
Other options: regular low dose ICS for patients with exacerbation risks.
STEP 2: Regular low dose ICS plus as-needed SABA
Other options: LTRA are less effective than ICS; ICS/LABA leads to faster
improvement in symptoms and FEV1 than ICS alone but is more expensive
and the exacerbation rate is similar. For purely seasonal allergic asthma,
start ICS immediately and cease 4 weeks after end of exposure.
STEP 3: Low dose ICS/LABA either as maintenance treatment plus as-
needed SABA, or as ICS/formoterol maintenance and reliever therapy
For patients with ≥1 exacerbation in the last year, low dose BDP/formoterol
or BUD/formoterol maintenance and reliever strategy is more effective than
maintenance ICS/LABA with as-needed SABA.
Other options: Medium dose ICS
Children (6–11 years): Medium dose ICS. Other options: low dose
ICS/LABA
STEP 4: Low dose ICS/formoterol maintenance and reliever therapy, or
medium dose ICS/LABA as maintenance plus as-needed SABA
Other options: Add-on tiotropium by mist inhaler for patients ≥12 years with
a history of exacerbations; high dose ICS/LABA, but more side-effects and
little extra benefit; extra controller, e.g. LTRA or slow-release theophylline
(adults)
Children (6–11 years): Refer for expert assessment and advice.
STEP 5: Refer for expert investigation and add-on treatment
Add-on treatments include tiotropium by mist inhaler for patients with a
history of exacerbations (age ≥12 years), omalizumab (anti-IgE) for severe
allergic asthma, and mepolizumab (anti-IL5) for severe eosinophilic asthma
(age ≥12 years). Sputum-guided treatment, if available, improves outcomes.
Other options: Some patients may benefit from low dose OCS but long-term
systemic side-effects occur.
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17. 17
REVIEWING RESPONSE AND ADJUSTING TREATMENT
How often should patients with asthma be reviewed?
Patients should preferably be seen 1–3 months after starting treatment and
every 3–12 months after that, except in pregnancy when they should be
reviewed every 4–6 weeks. After an exacerbation, a review visit within 1 week
should be scheduled. The frequency of review depends on the patient’s initial
level of control, their response to previous treatment, and their ability and
willingness to engage in self-management with an action plan.
Stepping up asthma treatment
Asthma is a variable condition, and periodic adjustment of controller treatment
by the clinician and/or patient may be needed.
• Sustained step-up (for at least 2–3 months): if symptoms and/or
exacerbations persist despite 2–3 months of controller treatment, assess
the following common issues before considering a step-up
o Incorrect inhaler technique
o Poor adherence
o Modifiable risk factors, e.g. smoking
o Are symptoms due to comorbid conditions, e.g. allergic rhinitis
• Short-term step-up (for 1–2 weeks) by clinician or by patient with written
asthma action plan (p22), e.g. during viral infection or allergen exposure
• Day-to-day adjustment by patient for patients prescribed low dose
beclometasone/formoterol or budesonide/formoterol as maintenance and
reliever therapy.
Stepping down treatment when asthma is well-controlled
Consider stepping down treatment once good asthma control has been
achieved and maintained for 3 months, to find the lowest treatment that
controls both symptoms and exacerbations, and minimizes side-effects.
• Choose an appropriate time for step-down (no respiratory infection,
patient not travelling, not pregnant)
• Document baseline status (symptom control and lung function), provide a
written asthma action plan, monitor closely, and book a follow-up visit
• Step down through available formulations to reduce the ICS dose by
25–50% at 2–3 month intervals (see full GINA report for details of how to
step down different controller treatments)
• Do not completely withdraw ICS (in adults or adolescents) unless it is
needed temporarily to confirm the diagnosis of asthma
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18. 18
INHALER SKILLS AND ADHERENCE
Provide skills training for effective use of inhaler devices
Most patients (up to 80%) cannot use their inhaler correctly. This contributes
to poor symptom control and exacerbations. To ensure effective inhaler use:
• Choose the most appropriate device for the patient before prescribing:
consider medication, physical problems e.g. arthritis, patient skills, and
cost; for ICS by pressurized metered dose inhaler, prescribe a spacer.
• Check inhaler technique at every opportunity. Ask the patient to show
you how they use the inhaler. Check their technique against a device-
specific checklist.
• Correct using a physical demonstration, paying attention to incorrect
steps. Check technique again, up to 2–3 times if necessary.
• Confirm that you have checklists for each of the inhalers you prescribe,
and can demonstrate correct technique on them.
Information about inhaler devices and techniques for their use can be found
on the GINA website (www.ginasthma.org) and the ADMIT website
(www.admit-inhalers.org).
Check and improve adherence with asthma medications
Around 50% of adults and children do not take controller medications as
prescribed. Poor adherence contributes to poor symptom control and
exacerbations. It may be unintentional (e.g. forgetfulness, cost,
misunderstandings) and/or non-intentional (e.g. not perceiving the need for
treatment, fear of side-effects, cultural issues, cost).
To identify patients with adherence problems:
• Ask an empathic question, e.g. “Most patients don’t take their inhaler
exactly as prescribed. In the last 4 weeks, how many days a week have
you been taking it? 0 days a week, or 1, or 2 days [etc]?”, or “Do you find
it easier to remember your inhaler in the morning or night?”
• Check medication usage, from prescription date, inhaler date/dose
counter, dispensing records
• Ask about attitudes and beliefs about asthma and medications
Only a few adherence interventions have been studied closely in asthma.
• Shared decision-making for medication and dose choice
• Inhaler reminders for missed doses
• Reduced complexity of the regimen (once- vs twice-daily)
• Comprehensive asthma education with home visits by asthma nurses
• Clinicians reviewing feedback on their patients’ dispensing records
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19. 19
TREATING MODIFIABLE RISK FACTORS
Exacerbation risk can be minimized by optimizing asthma medications, and
by identifying and treating modifiable risk factors. Some examples of risk
modifiers with consistent high quality evidence are:
• Guided self-management: self-monitoring of symptoms and/or PEF, a
written asthma action plan (p22), and regular medical review
• Use of a regimen that minimizes exacerbations: prescribe an ICS-
containing controller. For patients with 1 or more exacerbations in the last
year, consider a low dose ICS/formoterol maintenance and reliever
regimen
• Avoidance of exposure to tobacco smoke
• Confirmed food allergy: appropriate food avoidance; ensure availability
of injectable epinephrine for anaphylaxis
• For patients with severe asthma: refer to a specialist center, if
available, for consideration of add-on medications and/or sputum-guided
treatment.
NON-PHARMACOLOGICAL STRATEGIES AND INTERVENTIONS
In addition to medications, other therapies and strategies may be considered
where relevant, to assist in symptom control and risk reduction. Some
examples with consistent high quality evidence are:
• Smoking cessation advice: at every visit, strongly encourage smokers to
quit. Provide access to counselling and resources. Advise parents and
carers to exclude smoking in rooms/cars used by children with asthma
• Physical activity: encourage people with asthma to engage in regular
physical activity because of its general health benefits. Provide advice
about management of exercise-induced bronchoconstriction.
• Occupational asthma: ask all patients with adult-onset asthma about their
work history. Identify and remove occupational sensitizers as soon as
possible. Refer patients for expert advice, if available.
• NSAIDs including aspirin: always ask about asthma before prescribing.
Although allergens may contribute to asthma symptoms in sensitized patients,
allergen avoidance is not recommended as a general strategy for asthma.
These strategies are often complex and expensive, and there are no validated
methods for identifying those who are likely to benefit.
Some common triggers for asthma symptoms (e.g. exercise, laughter) should
not be avoided, and others (e.g. viral respiratory infections, stress) are
difficult to avoid and should be managed when they occur.
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20. 20
TREATMENT IN SPECIAL POPULATIONS OR CONTEXTS
Pregnancy: asthma control often changes during pregnancy. For baby and
mother, the advantages of actively treating asthma markedly outweigh any
potential risks of usual controller and reliever medications. Down-titration has
a low priority in pregnancy. Exacerbations should be treated aggressively.
Rhinitis and sinusitis often coexist with asthma. Chronic rhinosinusitis is
associated with more severe asthma. For some patients with allergic rhinitis,
treatment with intranasal corticosteroids improves asthma control.
Obesity: to avoid over- or under-treatment, it is important to document the
diagnosis of asthma in the obese. Asthma is more difficult to control in
obesity. Weight reduction should be included in the treatment plan for obese
patients with asthma; even 5–10% weight loss can improve asthma control.
The elderly: comorbidities and their treatment should be considered and may
complicate asthma management. Factors such as arthritis, eyesight,
inspiratory flow, and complexity of treatment regimens should be considered
when choosing medications and inhaler devices.
Gastroesophageal reflux (GERD) is commonly seen in asthma.
Symptomatic reflux should be treated for its general health benefits, but there
is no benefit from treating asymptomatic reflux in asthma.
Anxiety and depression: these are commonly seen in people with asthma,
and are associated with worse symptoms and quality of life. Patients should
be assisted to distinguish between symptoms of anxiety and of asthma.
Aspirin-exacerbated respiratory disease (AERD): a history of exacerbation
following ingestion of aspirin or other NSAIDs is highly suggestive. Patients
often have severe asthma and nasal polyposis. Confirmation of the diagnosis
of AERD requires challenge in a specialized center with cardiopulmonary
resuscitation facilities, but avoidance of NSAIDs may be recommended on the
basis of a clear history. ICS are the mainstay of treatment, but OCS may be
required. Desensitization under specialist care is sometimes effective.
Food allergy and anaphylaxis: food allergy is rarely a trigger for asthma
symptoms. It must be assessed with specialist testing. Confirmed food allergy
is a risk factor for asthma-related death. Good asthma control is essential;
patients should also have an anaphylaxis plan and be trained in appropriate
avoidance strategies and use of injectable epinephrine.
Surgery: whenever possible, good asthma control should be achieved pre-
operatively. Ensure that controller therapy is maintained throughout the peri-
operative period. Patients on long-term high dose ICS, or having more than 2
weeks’ OCS in the past 6 months, should receive intra-operative
hydrocortisone to reduce the risk of adrenal crisis.
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21. 21
ASTHMA FLARE-UPS (EXACERBATIONS)
A flare-up or exacerbation is an acute or sub-acute worsening in symptoms
and lung function from the patient’s usual status; occasionally it may be the
initial presentation of asthma.
For discussion with patients, the word ‘flare-up’ is preferred. ‘Episodes’,
‘attacks’ and ‘acute severe asthma’ are often used, but they have variable
meanings, particularly for patients.
The management of worsening asthma and exacerbations should be
considered as a continuum, from self-management by the patient with a
written asthma action plan, through to management of more severe
symptoms in primary care, the emergency department and in hospital.
Identifying patients at risk of asthma-related death
These patients should be identified, and flagged for more frequent review.
• A history of near-fatal asthma requiring intubation and ventilation
• Hospitalization or emergency care for asthma in last 12 months
• Not currently using ICS, or poor adherence with ICS
• Currently using or recently stopped using OCS (this indicates the severity
of recent events)
• Over-use of SABAs, especially more than 1 canister/month
• Lack of a written asthma action plan
• History of psychiatric disease or psychosocial problems
• Confirmed food allergy in a patient with asthma
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WRITTEN ASTHMA ACTION PLANS
All patients should be provided with a written asthma action plan appropriate
for their level of asthma control and health literacy, so they know how to
recognize and respond to worsening asthma.
Box 9. Self-management with a written action plan
The written asthma action plan should include:
• The patient’s usual asthma medications
• When and how to increase medications, and start OCS
• How to access medical care if symptoms fail to respond
The action plan can be based on symptoms and/or (in adults) PEF. Patients
who deteriorate quickly should be advised to go to an acute care facility or
see their doctor immediately.
Medication changes for written asthma action plans
Increase frequency of inhaled reliever (SABA, or low dose ICS/formoterol if
using maintenance and reliever regimen); add spacer for pMDI.
Increase controller: Rapid increase in ICS component up to max. 2000mcg
BDP equivalent. Options depend on usual controller medication, as follows:
• ICS: At least double dose, consider increasing to high dose.
• Maintenance ICS/formoterol: Quadruple maintenance ICS/formoterol
dose (to maximum formoterol dose of 72 mcg/day).
• Maintenance ICS/salmeterol: Step up at least to higher dose formulation;
consider adding separate ICS inhaler to achieve high ICS dose.
• Maintenance and reliever ICS/formoterol: Continue maintenance dose;
increase as-needed ICS/formoterol (maximum formoterol 72 mcg/day).
Oral corticosteroids (preferably morning dosing):
• Adults - prednisolone 1mg/kg/day up to 50mg, usually for 5–7 days.
• For children, 1–2 mg/kg/day up to 40mg, usually for 3–5 days.
• Tapering not needed if treatment has been given for less than 2 weeks.
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MANAGING EXACERBATIONS IN PRIMARY OR ACUTE CARE
Assess exacerbation severity while starting SABA and oxygen. Assess
dyspnea (e.g. is the patient able to speak sentences, or only words),
respiratory rate, pulse rate, oxygen saturation and lung function (e.g. PEF).
Check for anaphylaxis.
Consider alternative causes of acute breathlessness (e.g. heart failure,
upper airway dysfunction, inhaled foreign body or pulmonary embolism).
Arrange immediate transfer to an acute care facility if there are signs of
severe exacerbation, or to intensive care if the patient is drowsy, confused, or
has a silent chest. For these patients, immediately give inhaled SABA, inhaled
ipratropium bromide, oxygen and systemic corticosteroids.
Start treatment with repeated doses of SABA (usually by pMDI and spacer),
early oral corticosteroids, and controlled flow oxygen if available. Check
response of symptoms and saturation frequently, and measure lung function
after 1 hour. Titrate oxygen to maintain saturation of 93–95% in adults and
adolescents (94–98% in children 6–12 years).
For severe exacerbations, add ipratropium bromide, and consider giving
SABA by nebulizer. In acute care facilities, intravenous magnesium sulfate
may be considered if the patient is not responding to intensive initial
treatment.
Do not routinely perform chest X-ray or blood gases, or prescribe antibiotics,
for asthma exacerbations.
REVIEWING RESPONSE
Monitor patients closely and frequently during treatment, and titrate
treatment according to response. Transfer the patient to higher level care if
worsening or failing to respond.
Decide about need for hospitalization based on clinical status,
symptomatic and lung function, response to treatment, recent and past history
of exacerbations, and ability to manage at home.
Before discharge, arrange ongoing treatment. For most patients, prescribe
regular controller therapy (or increase current dose) to reduce the risk of
further exacerbations. Continue increased controller doses for 2–4 weeks,
and reduce reliever to as-needed. Check inhaler technique and adherence.
Provide an interim written asthma action plan.
Arrange early follow-up after any exacerbation, within 2–7 days.
Consider referral for specialist advice for patients with an asthma
hospitalization, or repeated emergency department presentations.
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Box 10. Management of asthma exacerbations in primary care
O2: oxygen; PEF: peak expiratory flow; SABA: short-acting beta2-agonist (doses are for
salbutamol)
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25. 25
FOLLOW-UP AFTER AN EXACERBATION
Exacerbations often represent failures in chronic asthma care, and they
provide opportunities to review the patient’s asthma management. All
patients must be followed up regularly by a health care provider until
symptoms and lung function return to normal.
Take the opportunity to review:
• The patient’s understanding of the cause of the exacerbation
• Modifiable risk factors for exacerbations, e.g. smoking
• Understanding of purposes of medications, and inhaler technique skills
• Review and revise written asthma action plan
Discuss medication use, as adherence with ICS and OCS may fall to 50%
within a week after discharge.
Comprehensive post-discharge programs that include optimal controller
management, inhaler technique, self-monitoring, written asthma action plan
and regular review are cost-effective and are associated with significant
improvement in asthma outcomes.
Referral for expert advice should be considered for patients who have been
hospitalized for asthma, or who re-present for acute asthma care.
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26. 26
GLOSSARY OF ASTHMA MEDICATION CLASSES
For more details, see full GINA 2016 report and Appendix (www.ginasthma.org) and
Product Information from manufacturers.
Medications Action and use Adverse effects
CONTROLLER MEDICATIONS
Inhaled corticosteroids
(ICS) (pMDIs or DPIs) e.g.
beclometasone,
budesonide, ciclesonide,
fluticasone propionate,
fluticasone furoate,
mometasone, triamcinolone
The most effective anti-inflammatory
medications for persistent asthma. ICS
reduce symptoms, increase lung function,
improve quality of life, and reduce the risk of
exacerbations and asthma-related
hospitalizations or death. ICS differ in their
potency and bioavailability, but most of the
benefit is seen at low doses (see Box 8
(p14) for low, medium and high doses of
different ICS).
Most patients using ICS do
not experience side-effects.
Local side-effects include
oropharyngeal candidiasis
and dysphonia. Use of
spacer with pMDI, and
rinsing with water and
spitting out after inhalation,
reduce local side effects.
High doses increase the
risk of systemic side-effects.
ICS and long-acting beta2
agonist bronchodilator
combinations (ICS/LABA)
(pMDIs or DPIs) e.g.
beclometasone/ formoterol,
budesonide/formoterol,
fluticasone furoate/
vilanterol, fluticasone
propionate/formoterol,
fluticasone propionate/
salmeterol, and
mometasone/formoterol.
When a medium dose of ICS alone fails to
achieve good control of asthma, the addition
of LABA to ICS improves symptoms, lung
function and reduces exacerbations in more
patients, more rapidly, than doubling the
dose of ICS. Two regimens are available:
maintenance ICS/LABA with SABA as
reliever, and low-dose combination
beclometasone or budesonide with
formoterol for maintenance and reliever
treatment.
The LABA component may
be associated with
tachycardia, headache or
cramps. Current
recommendations are that
LABA and ICS are safe for
asthma when used in
combination. Use of LABA
without ICS in asthma is
associated with increased
risk of adverse outcomes.
Leukotriene modifiers
(tablets) e.g. montelukast,
pranlukast, zafirlukast,
zileuton
Target one part of the inflammatory pathway
in asthma. Used as an option for controller
therapy, particularly in children. Used alone:
less effective than low dose ICS; added to
ICS: less effective than ICS/LABA.
Few side-effects except
elevated liver function tests
with zileuton and zafirlukast.
Chromones (pMDIs or
DPIs) e.g. sodium
cromoglycate and
nedocromil sodium
Very limited role in long-term treatment of
asthma. Weak anti-inflammatory effect, less
effective than low-dose ICS. Require
meticulous inhaler maintenance.
Side effects are uncommon
but include cough upon
inhalation and pharyngeal
discomfort.
Long-acting
anticholinergic
(tiotropium)
An add-on option at Step 4 or 5 by mist
inhaler for patients ≥12 years with a history
of exacerbations despite ICS ± LABA
Side-effects are uncommon
but include dry mouth.
Anti-IgE (omalizumab) An add-on option for patients with severe
persistent allergic asthma uncontrolled on
Step 4 treatment (high dose ICS/LABA).
Reactions at the site of
injection are common but
minor. Anaphylaxis is rare.
Anti-IL5 (mepolizumab) An add-on option for patients aged ≥12 yrs
with severe eosinophilic asthma uncontrolled
on Step 4 treatment (high dose ICS/LABA)
Headache and reactions at
injection site are common
but minor.
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Medications Action and use Adverse effects
Systemic corticosteroids
(tablets,suspension or
intramuscular (IM) or
intravenous (IV) injection)
e.g. prednisone,
prednisolone,
methylprednisolone,
hydrocortisone
Short-term treatment (usually 5–7 days in
adults) is important early in the treatment of
severe acute exacerbations, with main
effects seen after 4–6 hours. Oral
corticosteroid (OCS) therapy is preferred
and is as effective as IM or IV therapy in
preventing relapse. Tapering is required if
treatment given for more than 2 weeks.
Long-term treatment with OCS may be
required for some patients with severe
asthma.
Short-term use: some
adverse effects e.g.
hyperglycaemia, gastro-
intestinal side-effects, mood
changes.
Long-term use: limited by
the risk of significant
systemic adverse effects
e.g. cataract, glaucoma,
osteoporosis, adrenal
suppression. Patients
should be assessed for
osteoporosis risk and
treated appropriately.
RELIEVER MEDICATIONS
Short-acting inhaled
beta2-agonist
bronchodilators (SABA)
(pMDIs, DPIs and, rarely,
solution for nebulization or
injection) e.g. salbutamol
(albuterol), terbutaline.
Inhaled SABAs are medications of choice for
quick relief of asthma symptoms and
bronchoconstriction including in acute
exacerbations, and for pre-treatment of
exercise-induced bronchoconstriction.
SABAs should be used only as-needed at
the lowest dose and frequency required.
Tremor and tachycardia are
commonly reported with
initial use of SABA, but
tolerance to these effects
usually develops rapidly.
Excess use, or poor
response indicate poor
asthma control.
Short-acting
anticholinergics (pMDIs
or DPIs) e.g. ipratropium
bromide,
oxitropium bromide
Long-term use: ipratropium is a less
effective reliever medication than SABAs.
Short-term use in acute asthma: inhaled
ipratropium added to SABA reduces the risk
of hospital admission
Dryness of the mouth or a
bitter taste.
Abbreviations used in this pocket guide
BDP Beclometasone dipropionate
BUD Budesonide
DPI Dry powder inhaler
FEV1 Forced expiratory volume in 1 second
FVC Forced vital capacity
ICS Inhaled corticosteroids
LABA Long-acting beta2-agonists
n.a. Not applicable
O2 Oxygen
OCS Oral corticosteroids
PEF Peak expiratory flow
pMDI Pressurized metered dose inhaler
SABA Short-acting beta2-agonists
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ACKNOWLEDGEMENTS
The activities of the Global Initiative of Asthma are supported by the work of members
of the GINA Board of Directors and Committees (listed below). The members of the
GINA committees are solely responsible for the statements and recommendations
presented in this and other GINA publications.
GINA Board of Directors (2015)
J Mark FitzGerald, Canada, Chair; Eric Bateman, South Africa; Louis-Philippe Boulet*,
Canada; Alvaro Cruz*, Brazil; Tari Haahtela*, Finland; Mark Levy*, United Kingdom;
Paul O'Byrne, Canada; Soren Pedersen, Denmark; Helen Reddel, Australia; Stanley
Szefler, USA.
GINA Program: Suzanne Hurd, USA (to Dec 2015); Rebecca Decker, USA (from Jan
2016)
GINA Science Committee (2015)
Helen Reddel, Australia, Chair; Eric Bateman, South Africa.; Allan Becker, Canada ;
Johan de Jongste, The Netherlands; J. Mark FitzGerald, Canada; Hiromasa Inoue,
Japan; Jerry Krishnan, USA; Robert Lemanske, Jr., USA; Paul O'Byrne, Canada; Søren
Pedersen, Denmark; Emilio Pizzichini, Brazil; Stanley J. Szefler, USA.
GINA Dissemination and Implementation Committee (2015)
Louis-Philippe Boulet, Canada, Chair; other members indicated by asterisks (*) above.
GINA Assembly
The GINA Assembly includes members from 45 countries. Their names are listed on
the GINA website, www.ginasthma.org.
GINA PUBLICATIONS
• Global Strategy for Asthma Management and Prevention (updated 2016). This
report, provides an integrated approach to asthma that can be adapted for a wide
range of health systems. The report was extensively revised in 2014, and has been
updated yearly since then. The report has a user-friendly format with many practical
summary tables and flow-charts for use in clinical practice.
• GINA Online Appendix (updated 2016). Detailed background information to support
the main GINA report.
• Pocket Guide for asthma management and prevention for adults and children
older than 5 years (updated 2016). Summary for primary health care providers, to
be used in conjunction with the main GINA report.
• Pocket guide for asthma management and prevention in children 5 years and
younger (updated 2016). A summary of patient care information about pre-schoolers
with asthma or wheeze, to be used in conjunction with the main GINA 2016 report.
• Diagnosis of asthma-COPD overlap syndrome (ACOS) (updated 2015). This is a
stand-alone copy of the corresponding chapter in the main GINA report. It is co-
published by GINA and GOLD (the Global Initiative for Chronic Obstructive Lung
Disease, www.goldcopd.org).
• Clinical practice aids and implementation tools will be available on the GINA
website.
GINA publications and other resources are available from www.ginasthma.org
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