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GINA
At-A-Glance Asthma
Management Reference

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Revised 2009

GINA 2009 source documents are at www.ginasthma.org.


2010 Medical Communications Resources, Inc.

DIAGNOSING ASTHMA
Asthma can often be diagnosed on the basis of a patients symptoms and
medical history (e.g., see below).

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Has the patient had an attack or recurrent attacks of wheezing?


Does the patient have a troublesome cough at night?
Does the patient wheeze or cough after exercise?
Does the patient experience wheezeing, chest tightness, or cough after exposure
to airborne allergens or pollutants?
Do the patient's colds go to the chest or take more than 10 days to clear up?
Are symptoms improved by appropriate asthma treatment?

Questions to Consider in the Diagnosis of Asthma

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Measurements of lung function provide an assessment of the severity,


reversibility, and variability of airflow limitation, and help confirm the
diagnosis of asthma.

Spirometry is the preferred method of measuring airflow limitation and its


reversibility to establish a diagnosis of asthma.

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An increase in FEV1 of 12% and 200 ml after administration of a


bronchodilator indicates reversible airflow limitation consistent with
asthma. (However, most asthma patients will not exhibit reversibility at
each assessment, and repeated testing is advised.)

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Peak expiratory flow (PEF) measurements can be an important aid in both


diagnosis and monitoring of asthma.

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PEF measurements are ideally compared to the patients own previous


best measurements using his/her own peak flow meter.
An improvement of 60 L/min (or 20% of the pre-bronchodilator PEF)
after inhalation of a bronchodilator, or diurnal variation in PEF of more
than 20% (with twice-daily readings, more than 10%), suggests a
diagnosis of asthma.

Additional diagnostic tests:


For patients with symptoms consistent with asthma, but normal lung
function, measurements of airway responsiveness to methacholine,
histamine, direct airway challenges such as inhaled mannitol, or exercise
challenge may help establish a diagnosis of asthma.
Skin tests with allergens or measurement of specific IgE in serum:
The presence of allergies increases the probability of a diagnosis of
asthma, and can help to identify risk factors that cause asthma symptoms
in individual patients.

ASTHMA CONTROL

The goal of asthma care is to achieve and maintain control of the


clinical manifestations of the disease for prolonged periods. When
asthma is controlled, patients can prevent most attacks, avoid
troublesome symptoms day and night, and keep physically active.

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Levels of Asthma Control


Partly Controlled

Controlled

(Any m easure present in any w eek )

None (twice or less/week)

More than twice/week

None

Any

Nocturnal symptoms/
awakening

None

Need for reliever/


rescue treatment

None (twice or less/week)

More than twice/week

Lung function
(PEF or FEV1)

Normal

< 80% predicted or


personal best (if known)

Daytime symptoms
Limitations of activities

(Al l of th e f ol low in g)

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Characteristic

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The assessment of asthma control should include control of the clinical


manifestations and control of the expected future risk to the patient such
as exacerbations, accelerated decline in lung function, and side-effects
of treatment. In general, the achievement of good clinical control of
asthma leads to reduced risk of exacerbations.

Th r e e o r m or e
fea t u r es of
pa r t ly con t r olle d
as t h m a pr e s en t
in a n y w eek *

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Any

Uncontrolled

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B. Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side-effects)

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Features that are associated with increased risk of adverse events in the future include:
Poor clinical control, frequent exacerbations in past year, ever admission to critical care for asthma, low FEV1,
exposure to cigarette smoke, high dose medications.

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* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate.
By definition, an exacerbation in any week makes that an uncontrolled asthma week.
Lung function testing is not reliable for children 5 years and younger.

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Examples of validated measures for assessing clinical control of asthma


include:
Asthma Control Test (ACT): www.asthmacontrol.com
Childhood Asthma Control test (C-Act)
Asthma Control Questionnaire (ACQ):
www.qoltech.co.uk/Asthma1.htm
Asthma Therapy Assessment Questionnaire (ATAQ):
www.ataqinstrument.com
Asthma Control Scoring System

DOCTOR-PATIENT PARTNERSHIP
Essential Features of the Doctor-Patient Partnership to
Achieve Guided Self-Management in Asthma

Education and the Patient/Doctor Partnership

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Education
Joint setting of goals
Self-monitoring. The person with asthma is taught to combine assessment of asthma control with
educated interpretation of key symptoms
Regular review of asthma control, treatment, and skills by a health care professional
Written action plan. The person with asthma is taught which medications to use regularly and which
to use as needed, and how to adjust treatment in response to worsening asthma control
Self-monitoring is integrated with written guidelines for both the long-term treatment of asthma and
the treatment of asthma exacerbations.

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Goal: To provide the person with asthma, their family, and other caregivers with suitable information
and training so that they can keep well and adjust treatment according to a medication plan developed
with the health care professional.

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Focus on the development of the partnership


Acceptance that this is a continuing process
A sharing of information
Full discussion of expectations
Expression of fears and concerns

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Key components:

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Diagnosis
Difference between relievers and controllers
Use of inhaler devices
Prevention of symptoms and attacks
Signs that suggest asthma is worsening and actions to take
Monitoring control of asthma
How and when to seek medical attention

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Provide specific information, training, and advice about:

The person then requires:

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q A guided self-management plan


q Regular supervision, revision, reward, and reinforcement

Factors Involved in Non-Adherence

Drug factors
Difficulties with inhaler devices
Awkward regimes (e.g., four times
daily or multiple drugs)
Side effects
Cost of medication
Dislike of medication
Distant pharmacies

Non-drug factors
Misunderstanding or lack of instruction
Fears about side effects
Dissatisfaction with health care professionals
Unexpressed/undiscussed fears or concerns
Inappropriate expectations
Poor supervision, training, or follow-up
Anger about condition or its treatment
Underestimation of severity
Cultural issues
Stigmatization
Forgetfulness or complacency
Attitudes toward ill health
Religious issues

MANAGEMENT APPROACH
BASED ON CONTROL
Management Approach Based On Control

*** = Preferred controller options are shown in shaded boxes


**= Receptor antagonist or synthesis inhibitors
* ICS = inhaled glucocorticosteroids
theophylline
sustained release
Low-dose ICS plus
leukotriene modifier
Low-dose ICS plus

options***
Controller

modifier**
Leukotriene
ICS*
Low-dose inhaled
Select one

acting 2-agonist
As needed rapid-

theophylline
Sustained release
modifier
Leukotriene

high-dose ICS
Medium-or
long-acting 2-agonist
Low-dose ICS plus

2-agonist
ICS plus long-acting
Medium-or high-dose
select one or more
To Step 3 treatment,

Select one

treatment
Anti-IgE
(lowest dose)
Oral glucocorticosteroid
add either
To Step 4 treatment,

As needed rapid-acting 2-agonist


Environmental control
Asthma education

Step

Step

Step

Step

Treatment Steps

Reduce

Exacerbation

Step

Increase

Treat as exacerbation

esaercnI

Uncontrolled

Step up until controlled


Consider stepping up to gain control

Controlled

Maintain and find lowest controlling step

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Partly controlled

Level of Control

Treatment Action

For Children Older Than 5 Years, Adolescents and Adults

Management Approach Based On Control

E
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Treatment Action

Partly controlled

Consider stepping up to gain control

Uncontrolled

Step up until controlled

Treat as exacerbation

Step

Step

Step

Increase

Step

Step

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Treatment Steps

Reduce

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Exacerbation

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Maintain and find lowest controlling step

Increase

Controlled

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Level of Control

Reduce

For Children Older Than 5 Years, Adolescents and Adults

Asthma education
Environmental control
As needed rapidacting 2-agonist

Select one

To Step 3 treatment,
select one or more

To Step 4 treatment,
add either

Low-dose inhaled
ICS*

Low-dose ICS plus


long-acting 2-agonist

Medium-or high-dose
ICS plus long-acting
2-agonist

Oral glucocorticosteroid
(lowest dose)

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As needed rapid-acting 2-agonist

Medium-or
high-dose ICS

Leukotriene
modifier

Anti-IgE
treatment

Low-dose ICS plus


leukotriene modifier

Sustained release
theophylline

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Select one

Leukotriene
modifier**

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Controller
options***

Low-dose ICS plus


sustained release
theophylline

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* ICS = inhaled glucocorticosteroids


**= Receptor antagonist or synthesis inhibitors
*** = Preferred controller options are shown in shaded boxes

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Alternative reliever treatments include inhaled anticholinergics, short-acting oral 2-agonists, some
long-acting 2-agonists, and short-acting theophylline. Regular dosing with short and long-acting
2-agonist is not advised unless accompanied by regular use of an inhaled glucocorticosteroid.

For guidelines on management of asthma in children 5 years and younger, please refer to the
Global Strategy for the Diagnosis and Management of Asthma in Children 5 Years and Younger,
available at www.ginasthma.org.

SEVERITY OF ASTHMA
EXACERBATIONS
Respiratory
arrest imminent

Severe

Moderate

Mild
Walking

Talking
Infant - softer,
shorter cry;
difficulty feeding

Talks in

Sentences

Phrases

Words

Alertness

May be agitated

Usually agitated

Usually agitated

Respiratory rate

Increased

Increased

Often > 30/min

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Breathless

At rest
Infant stops
feeding

Drowsy or
confused
Paradoxical

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Paradoxical

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Guide to rates of breathing associated with respiratory distress in awake children


Age
Normal rate
< 2 months
< 60/min
2-12 months
< 50/min
1-5 years
< 40/min
6-8 years
< 30/min
Accessory
Usually
Usually not
thoracomuscles and
Usually
abdominal
suprasternal
movement
retractions

Pulse/min.

< 100

Loud

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Moderate, often
only end
expiratory

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Wheeze

100-120

Usually Loud

Absence of
wheeze

> 120

Bradycardia

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Guide to limits of normal pulse rate in children:


Infants
2-12 months
-Normal rate <160/min
Preschool
1-2 years
-Normal rate <120/min
School age
2-8 years
-Normal rate <110/min
Over 80%

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PEF
after initial
bronchodilator
% predicted or
% personal best
PaO2 (on air)*
and/or
PaCO2*

Normal Test
not usually
necessary
< 45 mmHg

SaO2% (on air)*

> 95%

Approximately
60-80%

> 60 mmHg

< 45 mmHg

91-95%

< 60% predicted


or personal best
(100 L/min
adults) or
response lasts
< 2 hours
< 60 mmHg
Possible cyanosis
> 45 mmHg:
Possible
respiratory
failure
< 90%

Hypercapnia (hypoventilation) develops more readily in young children than in adults and adolescents.

Management of Asthma Exacerbations in Acute Care Setting


Initial Assessment (see Figure 4.4-1)
History, physical examination (auscultation, use of accessory muscles, heart rate,
respiratory rate, PEF or FEV1, oxygen saturation, arterial blood gas if patient in extremis)

Initial Treatment
Oxygen to achieve O2 saturation 90% (95% in children)
Inhaled rapid-acting 2-agonist continuously for one hour.
Systemic glucocorticosteroids if no immediate response, or if patient recently took oral
glucocorticosteroid, or if episode is severe.
Sedation is contraindicated in the treatment of an exacerbation.

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Criteria for Severe Episode:


History of risk factors for near fatal asthma
PEF < 60% predicted/personal best
Physical exam: severe symptoms at rest,
chest retraction
No improvement after initial treatment
Treatment:
Oxygen
Inhaled 2-agonist and inhaled anticholinergic
Systemic glucocorticosteroids
Intravenous magnesium

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Criteria for Moderate Episode:


PEF 60-80% predicted/personal best
Physical exam: moderate symptoms,
accessory muscle use
Treatment:
Oxygen
Inhaled 2-agonist and inhaled anticholinergic
every 60 min
Oral glucocorticosteroids
Continue treatment for 1-3 hours, provided
there is improvement

Reassess after 1 Hour


Physical Examination, PEF, O2 saturation and other tests as needed

Reassess after 1-2 Hours

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Admit to Acute Care Setting


Oxygen
Inhaled 2-agonist
anticholinergic
Systemic glucocorticosteroid
Intravenous magnesium
Monitor PEF, O2 saturation,
pulse

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Incomplete Response
within 1-2 Hours:
Risk factors for near fatal
asthma
Physical exam: mild to
moderate signs
PEF < 60%
O2 saturation not improving

Admit to Intensive Care


Oxygen
Inhaled 2-agonist +
anticholinergic
Intravenous glucocorticosteroids
Consider intravenous
2-agonist
Consider intravenous
theophylline
Possible intubation and
mechanical ventilation

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Reassess at intervals

Poor Response (see above):


Admit to Intensive Care

Improved: Criteria for Discharge Home


PEF > 60% predicted/personal best
Sustained on oral/inhaled medication

Incomplete response in 6-12


hours (see above)
Consider admission to Intensive
Care if no improvement within
6-12 hours

Home Treatment:
Continue inhaled 2-agonist
Consider, in most cases, oral glucocorticosteroids
Consider adding a combination inhaler
Patient education: Take medicine correctly
Review action plan
Close medical follow-up

Poor Response within


1-2 Hours:
Risk factors for near fatal
asthma
Physical exam: symptoms
severe, drowsiness,
confusion
PEF < 30%
PCO2 > 45 mm Hg
P O2 < 60mm Hg

Good Response within


1-2 Hours:
Response sustained 60 min
after last treatment
Physical exam normal:
No distress
PEF > 70%
O2 saturation > 90%
(95% children)

Improved (see opposite)

EQUIPOTENT DOSES OF INHALED


GLUCOCORTICOSTEROIDS
Estimated Equipotent Daily Doses of Inhaled Glucocorticosteroids for Adults
High Daily
Dose (g)
>1000 - 2000
>800 - 1600
>320 - 1280
>2000
>500 - 1000
>800 - 1200
>2000

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>500 - 1000
>400 - 800
>160 - 320
>1000 - 2000
>250 - 500
>400 - 800
>1000 - 2000

Medium Daily
Dose (g)

Low Daily
Dose (g)

200 - 500
200 - 400
80 - 160
500 - 1000
100 - 250
200 - 400
400 - 1000

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Drug
Beclomethasone dipropionate
Budesonide*
Ciclesonide*
Flunisolide
Fluticasone
Mometasone furoate*
Triamcinolone acetonide

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Comparisons based upon efficacy data.


Patients considered for high daily doses except for short periods should be referred to a specialist for assessment to consider
alternative combinations of controllers. Maximum recommended doses are arbitrary but with prolonged use are associated with
increased risk of systemic side effects.
* Approved for once-daily dosing in mild patients.
Notes
The most important determinant of appropriate dosing is the clinicians judgment of the patients response to therapy. The clinician
must monitor the patients response in terms of clinical control and adjust the dose accordingly. Once control of asthma is achieved,
the dose of medication should be carefully titrated to the minimum dose required to maintain control, thus reducing the potential for
adverse effects.
Designation of low, medium, and high doses is provided from manufacturers recommendations where possible. Clear demonstration
of dose-response relationships is seldom provided or available. The principle is therefore to establish the minimum effective controlling
dose in each patient, as higher doses may not be more effective and are likely to be associated with greater potential for adverse
effects.
As CFC preparations are taken from the market, medication inserts for HFA preparations should be carefully reviewed by the clinician
for the equivalent correct dosage.

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*In these sections recommendations for doses of inhaled glucocorticosteroids are given as /day budesonide or equivalent, because a
majority of the clinical literature on these medications uses this standard.

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Estimated Equipotent Daily Doses of Inhaled Glucocorticosteroids for Children Older Than 5 Years

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Drug

Low Daily
Dose (g)

100 - 200
100 - 200
80 - 160
500 - 750
100 - 200
100 - 200
400 - 800

Medium Daily
Dose (g)
>200 - 400
>200 - 400
>160 - 320
>750 - 1250
>200 - 500
>200 - 400
>800 - 1200

High Daily
Dose (g)
>400
>400
>320
>1250
>500
>400
>1200

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Beclomethasone dipropionate
Budesonide*
Ciclesonide*
Flunisolide
Fluticasone
Mometasone furoate*
Triamcinolone acetonide

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Comparisons based upon efficacy data.


Patients considered for high daily doses except for short periods should be referred to a specialist for assessment to consider
alternative combinations of controllers. Maximum recommended doses are arbitrary but with prolonged use are associated with
increased risk of systemic side effects.
* Approved for once-daily dosing in mild patients.
Notes
The most important determinant of appropriate dosing is the clinicians judgment of the patients response to therapy. The clinician
must monitor the patients response in terms of clinical control and adjust the dose accordingly. Once control of asthma is achieved,
the dose of medication should be carefully titrated to the minimum dose required to maintain control, thus reducing the potential for
adverse effects.
Designation of low, medium, and high doses is provided from manufacturers recommendations where possible. Clear demonstration
of dose-response relationships is seldom provided or available. The principle is therefore to establish the minimum effective controlling
dose in each patient, as higher doses may not be more effective and are likely to be associated with greater potential for adverse
effects.
As CFC preparations are taken from the market, medication inserts for HFA preparations should be carefully reviewed by the clinician
for the equivalent correct dosage.

The Global Initiative for Asthma is supported by educational grants from: AstraZeneca, Boehringer Ingelheim,
Chiesi Group, Cipla, GlaxoSmithKline, Meda Pharma, Merck Sharp & Dohme, Mitusubishi Tanabe, Novartis,
Nycomed, and PharmAxis.
P r in t in g a n d d is t r ib u t ion h a s b e e n m a d e p os s ib l e b y a n e d u ca t io n a l g r a n t .