GINA - Guia ASMA 2017

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G IN A
lobal 
 itiative for 
sthma
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GINA Workshop Report
Topics:
 Definition
 Burden of Asthma
 Risk Factors
 Mechanisms
 Diagnosis and Classification
 Education and Delivery of Care
 Six Part Asthma Management Plan
 Research Recommendations
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Definition of Asthma
Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role 
Chronic inflammation causes an associated increase in airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning 
These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment
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Mechanisms Underlying the Definition of Asthma
Risk Factors
(for development of asthma)
INFLAMMATION
Airway
Hyperresponsiveness
Airflow Obstruction
 Risk Factors
(for exacerbations)
Symptoms
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Burden of Asthma
Asthma is one of the most common chronic diseases worldwide
Prevalence increasing in many countries, especially in children
A major cause of school/work absence
An overall increase in severity of asthma increases the pool of patients at risk for death
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Burden of Asthma
Health care expenditures very high
Developed economies might expect to spend 1-2 percent of total health care expenditures on asthma. Developing economies likely to face increased demand
Poorly controlled asthma is expensive; investment in prevention medication likely to yield cost savings in emergency care
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Worldwide Variation in Prevalence of Asthma Symptoms
International Study of Asthma and Allergies in Children (ISAAC)
Lancet 1998;351:1225
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Increasing Prevalence of Asthma in Children/Adolescents
0
5
10
15
20
25
30
35
1992
1982
1989
1975
1992
1982
1994
1989
1992
1982
1992
1982
1991
1979
1989
1966
Finland
(Haahtela et al)
Sweden
(Aberg et al)
Japan
(Nakagomi et al)
Scotland
(Rona et al)
UK
(Omran et al)
USA
(NHIS)
New Zealand
(Shaw et al)
Australia
(Peat et al)
{
Prevalence (%)
{
{
{
{
{
{
{
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70
60
50
40
30
20
85
86
87
88
89
90
91
92
93
94
Rate/1,000 Persons
Year
<18
18-44
45-64
65+
Total (All Ages)
Age (years)
Trends in Prevalence of Asthma By Age, U.S., 1985-1996
95
96
80
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Hospitalization Rates for Asthma by Age, U.S., 1974 - 1997
40
35
30
25
20
15
74
76
78
80
82
84
86
88
Rate/100,000 Persons
10
5
0
90
92
94
<15
15-44
45-64
65+
96
Year
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4
3
1
1980
Rate/100,000 Persons
Year
2
0
1985
1990
1995
2000
Black Male
White Female
White Male
Black Female
Death Rates for Asthma By Race, Sex, U.S., 1980-1998
5
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Risk Factors for Asthma
Host factors: predispose individuals to, or protect them from, developing asthma
Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist
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Factors that Exacerbate Asthma
Allergens
Air Pollutants
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs
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Risk Factors that Lead to 
Asthma Development
Host Factors
Genetic predisposition
Atopy
Airway hyper-
 responsiveness
Gender
Race/Ethnicity
Environmental Factors
 Indoor allergens
 Outdoor allergens
 Occupational sensitizers
 Tobacco smoke
 Air Pollution
 Respiratory Infections
 Parasitic infections
 Socioeconomic factors
 Family size
 Diet and drugs
 Obesity
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Is it Asthma?
Recurrent episodes of wheezing
Troublesome cough at night
Cough or wheeze after exercise
Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants
Colds “go to the chest” or take more than 10 days to clear
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Asthma Diagnosis
History and patterns of symptoms
Physical examination
Measurements of lung function
Measurements of allergic status to identify risk factors
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Classification of Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment
Symptoms
Nocturnal
Symptoms
FEV1 or PEF
STEP 4
Severe Persistent
STEP 3
Moderate Persistent
STEP 2
Mild Persistent
STEP 1
Intermittent
Continuous
Limited physical activity
Daily
Attacks affect activity
> 1 time a week but < 1 time a day
< 1 time a week
Asymptomatic and normal PEF between attacks
Frequent
> 1 time week
> 2 times a month
 2 times a month
 60% predicted
Variability > 30%
60 - 80% predicted 
Variability > 30%
 80% predicted
Variability 20 - 30%
 80% predicted
Variability < 20%
The presence of one feature of severity is sufficient to place patient in that category.
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1. Educate Patients
2. Assess and Monitor Severity
3. Avoid Exposure to Risk Factors
4. Establish Medication Plans for 	Chronic Management: Adults and 	Children
5. Establish Plans for Managing 	Exacerbations
6. Provide Regular Follow-up Care
Six-Part Asthma Management
Program
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Six-Part Asthma Management Program
1.	Educate patients to develop a partnership in asthma management
2.	Assess and monitor asthma severity with symptom reports and measures of lung function as much as possible
3.	Avoid exposure to risk factors
4.	Establish medication plans for chronic management in children and adults
5.	Establish individual plans for managing exacerbations
6.	Provide regular follow-up care
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Six-part Asthma Management Program
Goals of Long-term Management
Achieve and maintain control of symptoms
Prevent asthma episodes or attacks
Maintain pulmonary function as close to normal levels as possible
Maintain normal activity levels, including exercise
Avoid adverse effects from asthma medications
Prevent development of irreversible airflow limitation
Prevent asthma mortality
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Six-part Asthma Management Program
Control of Asthma
Minimal (ideally no) chronic symptoms
Minimal (infrequent) exacerbations
No emergency visits
Minimal (ideally no) need for “as needed” use of 
	β2-agonist 
No limitations on activities, including exercise
PEF circadian variation of less than 20 percent
(Near) normal PEF
Minimal (or no) adverse effects from medicine
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Six-Part Asthma Management Program
The most effective management is to prevent airway inflammation by eliminating the causal factors
Asthma can be effectively controlled in most patients, although it can not be cured
The major factors contributing to asthma morbidity and mortality are under-diagnosis and inappropriate treatment
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Six-Part Asthma Management
Program
Any asthma more severe than intermittent asthma is more effectively controlled by treatment to suppress and reverse airway inflammation than by treatment only of acute bronchoconstriction and symptoms
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Six-part Asthma Management Program
Part 1: Educate Patients to Develop a Partnership 
Aim is guided self-management – giving patients the ability to control their asthma
Interventions, including use of written action plans, have been shown to reduce morbidity in both children and adults
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Six-part Asthma Management Program
Part 1: Educate Patients to Develop a Partnership 
Educate continually
Include the family
Provide information about asthma
Provide training on self-management skills
Emphasize a partnership among health care providers, the patient, and the patient’s family
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Six-part Asthma Management Program
Factors Associated with 
Non-Compliance in Asthma Care
Medication Usage
Difficulties associated with inhalers
Complicated regimens
Fears about, or actual side effects
Cost
Patient/Physician
 Misunderstanding/lack of information
 Underestimation of severity
 Attitudes
toward ill health
 Cultural factors
 Poor communication
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Six-part Asthma Management Program
Part 2: Assess and Monitor Asthma Severity with Symptom Reports and Measures of Lung Function
Symptom reports
Use of reliever medication
Nighttime symptoms
Activity limitations
Spirometry for initial assessment. Peak Expiratory Flow for follow-up:
Assess severity
Assess response to therapy
PEF monitoring at home
Important for those with poor perception of symptoms
Daily measurement recorded in a diary
Assesses the severity and predicts worsening
Guides the use of a zone system for asthma self-management
Arterial blood gas for severe exacerbations
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Typical Spirometric (FEV1) Tracings
1
Time (sec)
2
3
4
5
FEV1
Volume
Normal Subject
Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)
Note: Each FEV1 curve represents the highest of three repeat measurements
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A Simple Index of PEF Variation 
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Minimum morning PEF ( % recent best): 570/670 = 85%
(From Reddel, H.K. et al. 1995)
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Six-part Asthma Management Program
Part 3: Avoid Exposure to Risk Factors
Methods to prevent onset of asthma are not yet available but this remains an important goal
Measures to reduce exposure to causes of asthma exacerbations (e.g. allergens, pollutants, foods and medications) should be implemented whenever possible
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Six-part Asthma Management Program
Part 3: Avoid Exposure to Risk Factors
Reduce exposure to indoor allergens
Avoid tobacco smoke
Avoid vehicle emission
Identify irritants in the workplace
Explore role of infections on asthma development, especially in children and young infants
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Six-part Asthma Management Program
Part 4: Establish Medication Plans for Long-Term Asthma Management
A stepwise approach to pharmacological therapy is recommended 
The aim is to accomplish the goals of therapy with the least possible medication
Although in many countries traditional methods of healing are used, their efficacy has not yet been established and their use can therefore not be recommended
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Part 4: Long-term Asthma Management
Stepwise Approach to Asthma Therapy
The choice of treatment should be guided by: 
Severity of the patient’s asthma
Patient’s current treatment
Pharmacological properties and availability of the various forms of asthma treatment
Economic considerations
Cultural preferences and differing health care
systems need to be considered.
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Part 4: Long-term Asthma Management
Pharmacologic Therapy
Controller Medications:
Inhaled glucocorticosteroids
Systemic glucocorticosteroids
Cromones 
Methylxanthines
Long-acting inhaled β2-agonists
Long-acting oral β2-agonists
Leukotriene modifiers
Anti-IgE
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Part 4: Long-term Asthma Management Pharmacologic Therapy
Reliever Medications:
Rapid-acting inhaled β2-agonists
Systemic glucocorticosteroids
Anticholinergics
Methylxanthines
Short-acting oral β2-agonists
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Estimated Comparative Daily Dosages for Inhaled Glucocorticosteroids 
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Part 4: Long-term Asthma Management
Stepwise Approach to Asthma Therapy - Adults
Reliever:
Rapid-acting inhaled β2-agonist prn
Controller:
Daily inhaled
corticosteroid 
 
Controller:
Daily inhaled corticosteroid plus 
Daily long-acting inhaled β2-agonist
Controller:
Daily inhaled corticosteroid plus
Daily long –acting inhaled β2-agonist
plus (if needed) 
When asthma is controlled, reduce therapy
Monitor
STEP 1:
Intermittent
STEP 2:
Mild Persistent
STEP 3:
 Moderate Persistent
STEP 4:
Severe Persistent
STEP Down
Outcome: Asthma Control
Outcome: Best Possible Results
Alternative controller and reliever medications may be considered (see text). 
Controller:
None
 -Theophylline-SR
 -Leukotriene 
 -Long-acting inhaled
 β2- agonist
 -Oral corticosteroid
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Recommended Asthma Medications Step 1: Adults
Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried.
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Recommended Asthma Medications Step 2: Adults
Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried.
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Recommended Asthma Medications Step 3: Adults
Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried.
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Recommended Asthma Medications Step 4: Adults
Reliever Medication: Rapid-acting inhaled β2- agonist prn, not more than 3-4 times a day. Once control is achieved and maintained for at least 3 months, gradual reduction of therapy should be tried.
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Six-part Asthma Management Program
Part 4: Establish Medication Plans for Long-Term Asthma Management in Infants and Children
Childhood and adult asthma share the same underlying mechanisms. However, because of processes of growth and development, effects of asthma treatments in children differ from those in adults.
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Six-part Asthma Management Program
Part 4: Establish Medication Plans for Long-Term Asthma Management in Infants and Children
Many asthma medications (e.g. glucocorticosteroids, β2- agonists, theophylline) are metabolized faster in children than in adults, and younger children tend to metabolize medications faster than older children
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Six-part Asthma Management Program
Part 4: Establish Medication Plans for Long-Term Asthma Management in Infants and Children
Long-term treatment with inhaled glucocorticosteroids has not been shown to be associated with any increase in osteoporosis or bone fracture
Studies including a total of over 3,500 children treated for periods of 1 – 13 years have found no sustained adverse effect of inhaled glucocorticosteroids on growth
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Six-part Asthma Management Program
Part 4: Establish Medication Plans for Long-Term Asthma Management in Infants and Children
Rapid-acting inhaled β2- agonists are the most effective reliever therapy for children
These medications are the most effective bronchodilators available and are the treatment of choice for acute asthma symptoms
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Six-part Asthma Management Program
Part 5: Establish Plans for Managing Exacerbations
Treatment of exacerbations depends on:
The patient
Experience of the health care professional
Therapies that are the most effective for the particular patient
Availability of medications
Emergency facilities
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Six-part Asthma Management Program
Part 5: Establish Plans for Managing Exacerbations
Primary therapies for exacerbations:
Repetitive administration of rapid-acting inhaled β2-agonist
Early introduction of systemic glucocorticosteroids
Oxygen supplementation
Closely monitor response to treatment
with serial measures of lung function
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Six-part Asthma Management Program
Part 5: Managing Severe Asthma Exacerbations
Severe exacerbations are life-threatening medical emergencies 
Care must be expeditious and treatment is often most safely undertaken in a hospital or hospital-based emergency department
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Emergency Department Management Acute Asthma
Respiratory Failure
Admit to ICU
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Six-part Asthma Management Program
Part 6: Provide Regular Follow-up Care
Continual monitoring is essential to assure that
therapeutic goals are met. Frequent follow-up visits
are necessary to review:
Home PEF and symptom records
Techniques in use of medications
Risk factors and their control
Once asthma control is established, follow-up
visits should be scheduled (at 1 to 6 month intervals
as appropriate)
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Six-part Asthma Management Program
Special Considerations
Special considerations are required to
manage asthma in relation to:
Pregnancy
Surgery
Physical activity
Rhinitis, sinusitis, and nasal polyps
Occupational asthma
Respiratory infections
Gastroesophageal reflux
Aspirin-induced asthma
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Six-part Asthma Management Program: Summary
Asthma can be effectively controlled, although it cannot be cured
Effective asthma management programs include education, objective measures of lung function, environmental control, and pharmacologic therapy
A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication
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Six-part Asthma Management Program: Summary (continued)
Anything more than mild, occasional asthma is more effectively controlled by suppressing inflammation than by only treating acute bronchospasm
The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered 
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http://www.ginasthma.com
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Part 4: Long-term Asthma Management
Stepwise Approach to Asthma Therapy - Adults
Reliever:
Rapid-acting inhaled β2-agonist prn
Controller:
Daily inhaled
corticosteroid 
 
Controller:
Daily inhaled corticosteroid 
Daily long-acting inhaled β2-agonist
Controller:
Daily inhaled corticosteroid 
Daily long –acting inhaled β2-agonist
plus(if needed) 
When asthma is controlled, reduce therapy
Monitor
STEP 1:
Intermittent
STEP 2:
Mild Persistent
STEP 3:
Moderate Persistent
STEP 4:
Severe Persistent
STEP Down
Outcome: Asthma Control
Outcome: Best Possible Results
Alternative controller and reliever medications may be considered (see text). 
Controller:
None
 -Theophylline-SR
 -Leukotriene 
 -Long-acting inhaled
 β2- agonist
 -Oral corticosteroid
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Stepwise Approach to Asthma Therapy: Adults 
Step 1: Intermittent Asthma 
None required
Rapid-acting inhaled 2-agonist
for symptoms (but < once a week)
 
Rapid-acting inhaled 2-agonist,
cromone, or leukotriene modifier 
before exercise or exposure to
allergen
Continuously review medication technique, compliance and environmental control
Review treatment every three months.
Step up if control is not achieved; step down if control is sustained for at least 3 months
Preferred treatments are in bold print
Daily Controller Medications
Reliever 
Medications
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Low-dose inhaled 
glucocorticosteroid 
Other options (order by cost):
sustained-release theophylline, or
Cromone, or 
leukotriene modifier
Rapid-acting inhaled 2-agonist
for symptoms (but < 3-4 times/day)
Other options: 
inhaled anticholinergic, or
short-acting oral 2-agonist, or
short-acting theophylline
Continuously review medication technique, compliance and environmental control.
Review treatment every three months
Step up if control is not achieved; Step down if control is sustained for at least 3 months
Preferred treatments are in bold print
Stepwise Approach to Asthma Therapy: Adults Step 2: Mild Persistent Asthma
Daily Controller Medications
Reliever Medications
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Low- to medium-dose inhaled glucocortico-
steroid, plus long-acting inhaled 2-agonist 
Other options (order by cost):
Medium-dose inhaled glucocorticosteroid plus sustained-release theophylline, or
Medium-dose inhaled glucocorticosteroid plus long-acting inhaled β2- agonist, or
High-dose inhaled glucocorticosteroid, or
Medium-dose inhaled glucocorticosteroid plus leukotriene modifier
Rapid-acting inhaled 
2-agonist for symptoms 
(but < 3 - 4 times/day)
Other options: 
inhaled anticholinergic or
short-acting oral 
 2-agonist or
short-acting theophylline 
Continuously review medication technique, compliance and environmental control.
Review treatment every three months.
Step up if control is not achieved; Step down if control is sustained for at least 3 months.
Preferred treatments are in bold print.
Stepwise Approach to Asthma Therapy: Adults
Step 3: Moderate Persistent Asthma
Daily Controller 
Medications
Reliever Medications
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High-dose inhaled glucocorticosteroid,
plus long-acting inhaled β2agonist 
plus one or more of the following, if
needed (order by cost):
sustained-release theophylline, or
leukotriene modifier or
oral glucocorticosteroid
Rapid-acting inhaled 
2-agonist for symptoms 
(but < 3-4 times/day)
Other options: 
inhaled anticholinergic or
short-acting oral 
 2-agonist or
short-acting theophylline
Continuously review medication technique, compliance and environmental control.
Review treatment every three months.
Step up if control is not achieved; Step down if control is sustained for at least 3 months.
Preferred treatments are in bold print.
Stepwise Approach to Asthma Therapy: Adults
Step 4: Severe Persistent Asthma
Daily Controller 
Medications
Reliever Medications