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GLOBAL INITIATIVE FOR ASTHMA (GINA) TEACHING SLIDE SET

January 2013
This slide set is restricted for academic and educational purposes only. Use of the slide set, or of individual slides, for commercial or promotional purposes requires approval from GINA.

Global Initiative for Asthma

G lobal INitiative for A sthma


Global Initiative for Asthma

GINA Program Objectives


Increase appreciation of asthma as a global public health problem
Present key recommendations for diagnosis and management of asthma Provide strategies to adapt recommendations to varying health needs, services, and resources

Identify areas for future investigation of particular significance to the global community
Global Initiative for Asthma

GINA Structure
Executive Committee
Chair: Mark FitzGerald, MD

Dissemination Committee
Chair: L.B. Boulet, MD

Science Committee
Chair: Helen Reddel, MD

Global Initiative for Asthma

GINA Board of Directors


M. FitzGerald, Chair, Canada E. Bateman, S. Africa P. Paggario, Italy L.P. Boulet, Canada S. Pedersen, Denmark A. Cruz, Brazil H. Reddel, Australia M. Haahtela, Finland M. Soto-Quiroz, Costa Rica M. Levy, U.K. G. Wong, Hong Kong ROC P. OByrne, Canada
Global Initiative for Asthma

GINA Science Committee


H. Reddel, Chair, Australia N. Barnes, UK M. FitzGerald, Canada P. Barnes, UK R. Lemanske, US A. Becker, Canada P. OByrne, Canada E. Bel, Netherlands E. Pizzichini, Brazil J. DeJongste, Netherlands S. Pedersen, Denmark J. Drazen, US H. Reddel, Australia
Global Initiative for Asthma

GINA Structure
Executive Committee
Chair: Mark FitzGerald, MD

Dissemination Committee
Chair: L.P. Boulet, MD

Science Committee
Chair: H. Reddel, MD

GINA ASSEMBLY
Global Initiative for Asthma

GINA Assembly

A network of individuals participating in the dissemination and implementation of asthma management programs at the local, national and regional level GINA Assembly members are invited to meet with the GINA Executive Committee during the ATS and ERS meetings
Global Initiative for Asthma

Slovenia Germany Ireland Yugoslavia Croatia Australia Canada Brazil Austria United States Taiwan Portugal Thailand Philippines Malta Greece Mexico Moldova China Syria Egypt South Africa United Kingdom Hong Kong ROC Chile Italy New Zealand
Lebanon

Saudi Arabia

Bangladesh

Argentina

Venezuela Cambodia Israel Pakistan Japan


Netherlands

Mongolia

Poland Korea

GINA Assembly
Macedonia France
Belgium

Switzerland

Russia

Georgia
Denmark Spain Vietnam

Turkey Czech

India

Slovakia Republic Colombia Ukraine Romania Sweden


Albania

Singapore

Kyrgyzstan

GINA Documents
Global Strategy for Asthma Management and
Prevention (updated 2012)

Pocket Guide: Asthma Management and Prevention


(updated 2012)

Global Strategy for Asthma Management and


Prevention for Children 5 Years and Younger (2009)

Pocket Guide: Asthma Management and Prevention in


Children 5 Years and younger (2009)

Guide for asthma patients and families


All materials are available on GINA web site www.ginasthma.org
Global Initiative for Asthma

Global Strategy for Asthma Management and Prevention


Evidence-based Implementation oriented Diagnosis Management Prevention Outcomes can be evaluated
Global Initiative for Asthma

Global Strategy for Asthma Management and Prevention


Evidence Category Sources of Evidence
Randomized clinical trials Rich body of data Randomized clinical trials Limited body of data

A B

C
D

Non-randomized trials Observational studies


Panel judgment consensus
Global Initiative for Asthma

Global Strategy for Asthma Management and Prevention (2012) Definition and Overview Diagnosis and Classification Asthma Medications Asthma Management and Prevention Program Implementation of Asthma Guidelines in Health Systems

Global Initiative for Asthma

Updated 2012

Definition of Asthma

A chronic inflammatory disorder of the airways


Many cells and cellular elements play a role Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing

Widespread, variable, and often reversible airflow limitation


Global Initiative for Asthma

Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, MD

Mechanisms: Asthma Inflammation

Source: Peter J. Barnes, MD

Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, MD

Burden of Asthma

Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals Prevalence increasing in many countries, especially in children A major cause of school/work absence
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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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Asthma Prevalence and Mortality

Source: Masoli M et al. Allergy 2004

Countries should enter their own data on burden of asthma.

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 Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs
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Factors that Influence Asthma Development and Expression


Host Factors Genetic - Atopy - Airway hyperresponsiveness Gender Obesity Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Diet

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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 Measurements of lung function - Spirometry - Peak expiratory flow Measurement of airway responsiveness Measurements of allergic status to identify risk factors Extra measures may be required to diagnose asthma in children 5 years and younger and the elderly
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Typical Spirometric (FEV1) Tracings


Volume FEV1

Normal Subject

Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)

2 3 4 Time (sec)

Note: Each FEV1 curve represents the highest of three repeat measurements
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Measuring Variability of Peak Expiratory Flow

Measuring Airway Responsiveness

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Asthma Management and Prevention Program: Five Components


1. Develop Patient/Doctor Partnership 2. Identify and Reduce Exposure to Risk Factors

3. Assess, Treat and Monitor Asthma


4. Manage Asthma Exacerbations
Updated 2012

5. Special Considerations
Global Initiative for Asthma

Asthma Management and Prevention Program

Goals of Long-term Management


Achieve and maintain control of symptoms Maintain normal activity levels, including exercise Maintain pulmonary function as close to normal levels as possible Prevent asthma exacerbations Avoid adverse effects from asthma medications Prevent asthma mortality

Global Initiative for Asthma

Asthma Management and Prevention Program: Five Interrelated Components

1. Develop Patient/Doctor Partnership

2. Identify and Reduce Exposure to Risk Factors 3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations 5. Special Considerations
Global Initiative for Asthma

Asthma Management and Prevention Program

Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.
Global Initiative for Asthma

Asthma Management and Prevention Program

Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control

Global Initiative for Asthma

Asthma Management and Prevention Program

Part 1: Educate Patients to Develop a Partnership Guidelines on asthma management should be available but adapted and adopted for local use by local asthma planning teams
Clear communication between health care professionals and asthma patients is key to enhancing compliance
Global Initiative for Asthma

Asthma Management and Prevention Program

Component 1: Develop Patient/Doctor 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 patients family
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Asthma Management and Prevention Program

Component 1: Develop Patient/Doctor Partnership Key factors to facilitate communication:


Friendly demeanor Interactive dialogue Encouragement and praise Provide appropriate information Feedback and review
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Example Of Contents Of An Action Plan To Maintain Asthma Control


Your Regular Treatment: 1. Each day take ___________________________ 2. Before exercise, take _____________________ WHEN TO INCREASE TREATMENT Assess your level of Asthma Control In the past week have you had: Daytime asthma symptoms more than 2 times ? No Yes Activity or exercise limited by asthma? No Yes Waking at night because of asthma? No Yes The need to use your [rescue medication] more than 2 times? No Yes If you are monitoring peak flow, peak flow less than________? No Yes If you answered YES to three or more of these questions, your asthma is uncontrolled and you may need to step up your treatment. HOW TO INCREASE TREATMENT STEP-UP your treatment as follows and assess improvement every day: ____________________________________________ [Write in next treatment step here] Maintain this treatment for _____________ days [specify number] WHEN TO CALL THE DOCTOR/CLINIC. Call your doctor/clinic: _______________ [provide phone numbers] If you dont respond in _________ days [specify number] ______________________________ [optional lines for additional instruction]

EMERGENCY/SEVERE LOSS OF CONTROL If you have severe shortness of breath, and can only speak in short sentences, If you are having a severe attack of asthma and are frightened, If you need your reliever medication more than every 4 hours and are not improving. 1. Take 2 to 4 puffs ___________ [reliever medication] 2. Take ____mg of ____________ [oral glucocorticosteroid] 3. Seek medical help: Go to _____________________; Address___________________ Phone: _______________________ 4. Continue to use your _________[reliever medication] until you are able to get medical help.

Global Initiative for Asthma

Asthma Management and Prevention Program

Factors Involved in Non-Adherence


Medication Usage

Non-Medication Factors

Difficulties associated with inhalers

Misunderstanding/lack of information Fears about side-effects Inappropriate expectations Underestimation of severity

Complicated regimens
Fears about, or actual side effects Cost Distance to pharmacies

Attitudes toward ill health


Cultural factors Poor communication

Global Initiative for Asthma

Asthma Management and Prevention Program

Component 2: Identify and Reduce Exposure to Risk Factors


Measures to prevent the development of asthma, and asthma exacerbations by avoiding or reducing exposure to risk factors should be implemented wherever possible. Asthma exacerbations may be caused by a variety of risk factors allergens, viral infections, pollutants and drugs. Reducing exposure to some categories of risk factors improves the control of asthma and reduces medications needs.
Global Initiative for Asthma

Asthma Management and Prevention Program

Component 2: Identify and Reduce 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
Global Initiative for Asthma

Asthma Management and Prevention Program

Influenza Vaccination

Influenza vaccination should be provided to patients with asthma when vaccination of the general population is advised However, routine influenza vaccination of children and adults with asthma does not appear to protect them from asthma exacerbations or improve asthma control
Global Initiative for Asthma

Asthma Management and Prevention Program

Component 3: Assess, Treat and Monitor Asthma The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional
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Clinical Control of Asthma


The focus on asthma control is
important because:

Global Strategy for Asthma Management and Prevention

the attainment of control correlates with a better quality of life, and reduction in health care use
Global Initiative for Asthma

Clinical Control of Asthma


Determine the initial level of control to implement treatment (assess patient impairment)

Global Strategy for Asthma Management and Prevention

Maintain control once treatment has been implemented (assess patient risk)
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Levels of Asthma Control


(Assess patient impairment)
Controlled
(All of the following)

Characteristic Daytime symptoms Limitations of activities Nocturnal symptoms / awakening Need for rescue / reliever treatment

Partly controlled
(Any present in any week)

Uncontrolled

Twice or less per week None

More than twice per week Any

None Twice or less per week

Any More than twice per week < 80% predicted or personal best (if known) on any day

3 or more features of partly controlled asthma present in any week

Lung function (PEF or FEV1)

Normal

Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side effects)
Global Initiative for Asthma

Assess Patient Risk


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
Global Initiative for Asthma

Assessment of Future Risk


Risk of exacerbations, instability, rapid decline in lungexacerbation function, side effects Any

should prompt review Features that are associated with increased of maintenance risk of adverse events in the future include: Poor clinical control treatment

Frequent exacerbations in past year Ever admission to critical care for asthma Low FEV1, exposure to cigarette smoke, high dose medications
Global Initiative for Asthma

Asthma Management and Prevention Program

Component 3: Assess, Treat and Monitor Asthma


Depending on level of asthma control, the patient is assigned to one of five treatment steps Treatment is adjusted in a continuous cycle driven by changes in asthma control status. The cycle involves: - Assessing Asthma Control

- Treating to Achieve Control


- Monitoring to Maintain Control
Global Initiative for Asthma

Asthma Management and Prevention Program

Component 3: Assess, Treat and Monitor Asthma

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
Global Initiative for Asthma

Asthma Management and Prevention Program

Component 3: Assess, Treat and Monitor Asthma


The choice of treatment should be guided by:

Level of asthma control 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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Controller Medications
Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled 2-agonists in combination with inhaled glucocorticosteroids Systemic glucocorticosteroids Theophylline Cromones Anti-IgE

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Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age


Drug
Beclomethasone Budesonide Budesonide-Neb Inhalation Suspension Ciclesonide Flunisolide Fluticasone Mometasone furoate Triamcinolone acetonide 80 160 500-1000 100-250 200-400 400-1000 Low Daily Dose (g) > 5 y Age < 5 y 200-500 200-600 100-200 100-200 250-500 80-160 500-750 100-200 100-200 400-800 >160-320 >1000-2000 >250-500 > 400-800 >1000-2000 Medium Daily Dose (g) > 5 y Age < 5 y >500-1000 600-1000 >200-400 >200-400 500-1000 >160-320 >750-1250 >200-500 >200-400 >800-1200 >320-1280 >2000 >500 >800-1200 >2000 High Daily Dose (g) > 5 y Age < 5 y >1000 >1000 >400 >400 >1000 >320 >1250 >500 >400 >1200

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Reliever Medications
Rapid-acting inhaled 2-agonists Systemic glucocorticosteroids Anticholinergics Theophylline Short-acting oral 2-agonists
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Component 4: Asthma Management and Prevention Program

Allergen-specific Immunotherapy

Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis The role of specific immunotherapy in asthma is limited Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma Perform only by trained physician
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LEVEL OF CONTROL
controlled partly controlled

REDUCE INCREASE

TREATMENT OF ACTION
maintain and find lowest controlling step consider stepping up to gain control

uncontrolled exacerbation

step up until controlled treat as exacerbation

REDUCE

INCREASE

TREATMENT STEPS
STEP STEP STEP STEP STEP

3
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TO STEP 3 TREATMENT, SELECT ONE OR MORE:

TO STEP 4 TREATMENT, ADD EITHER

Shaded green - preferred controller options

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

TO STEP 4 TREATMENT, ADD EITHER

Shaded green - preferred controller options

Treating to Achieve Asthma Control


Step 1 As-needed reliever medication

Patients with occasional daytime symptoms of short duration


A rapid-acting inhaled 2-agonist is the recommended reliever treatment (Evidence A) When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher)
Global Initiative for Asthma

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

TO STEP 4 TREATMENT, ADD EITHER

Shaded green - preferred controller options

Treating to Achieve Asthma Control


Step 2 Reliever medication plus a single controller A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (Evidence A) Alternative controller medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids
Global Initiative for Asthma

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

TO STEP 4 TREATMENT, ADD EITHER

Shaded green - preferred controller options

Treating to Achieve Asthma Control


Step 3 Reliever medication plus one or two controllers For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled longacting 2-agonist either in a combination inhaler device or as separate components (Evidence A) Inhaled long-acting 2-agonist must not be used as monotherapy For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)
Global Initiative for Asthma

Treating to Achieve Asthma Control


Additional Step 3 Options for Adolescents and Adults

Increase to medium-dose inhaled glucocorticosteroid (Evidence A) Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A) Low-dose sustained-release theophylline (Evidence B)
Global Initiative for Asthma

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

TO STEP 4 TREATMENT, ADD EITHER

Shaded green - preferred controller options

Treating to Achieve Asthma Control


Step 4 Reliever medication plus two or more controllers

Selection of treatment at Step 4 depends on prior selections at Steps 2 and 3

Where possible, patients not controlled on Step 3 treatments should be referred to a health professional with expertise in the management of asthma
Global Initiative for Asthma

Treating to Achieve Asthma Control


Step 4 Reliever medication plus two or more controllers

Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled 2-agonist (Evidence A) Medium- or high-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A) Low-dose sustained-release theophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled 2-agonist (Evidence B)
Global Initiative for Asthma

TO STEP 3 TREATMENT, SELECT ONE OR MORE:

TO STEP 4 TREATMENT, ADD EITHER

Shaded green - preferred controller options

Treating to Achieve Asthma Control


Step 5 Reliever medication plus additional controller options

Addition of oral glucocorticosteroids to other controller medications may be effective (Evidence D) but is associated with severe side effects (Evidence A) Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)
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Treating to Maintain Asthma Control

When control as been achieved, ongoing monitoring is essential to:


- maintain control

- establish lowest step/dose treatment

Asthma control should be monitored by the health care professional and by the patient
Global Initiative for Asthma

Treating to Maintain Asthma Control


Stepping down treatment when asthma is controlled

When controlled on medium- to high-dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals (Evidence B) When controlled on low-dose inhaled glucocorticosteroids: switch to once-daily dosing (Evidence A)
Global Initiative for Asthma

Treating to Maintain Asthma Control


Stepping down treatment when asthma is controlled

When controlled on combination inhaled glucocorticosteroids and long-acting inhaled 2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting 2-agonist (Evidence B)
If control is maintained, reduce to lowdose inhaled glucocorticosteroids and stop long-acting 2-agonist (Evidence D)
Global Initiative for Asthma

Treating to Maintain Asthma Control


Stepping up treatment in response to loss of control

Rapid-onset, short-acting or longacting inhaled 2-agonist bronchodilators provide temporary relief. Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy
Global Initiative for Asthma

Treating to Maintain Asthma Control


Stepping up treatment in response to loss of control

Use of a combination rapid and long-acting inhaled 2-agonist (e.g., formoterol) and an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a controller and reliever is effecting in maintaining a high level of asthma control and reduces exacerbations (Evidence A) Doubling the dose of inhaled glucocorticosteroids is not effective, and is not recommended (Evidence A)
Global Initiative for Asthma

Asthma Management and Prevention Program

Component 4: Manage Asthma Exacerbations


Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness
Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)

Severe exacerbations are potentially lifethreatening and treatment requires close supervision
Global Initiative for Asthma

Asthma Management and Prevention Program

Component 4: Manage Asthma 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
Global Initiative for Asthma

Asthma Management and Prevention Program

Component 4: Manage Asthma Exacerbations


Primary therapies for exacerbations:
Repetitive administration of rapid-acting inhaled 2-agonist Early introduction of systemic glucocorticosteroids Oxygen supplementation

Closely monitor response to treatment with serial measures of lung function


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Asthma Management and Prevention Program

Special Considerations
Special considerations are required to manage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma
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Global Strategy for the Diagnosis and Management of Asthma in Children 5 Years and Younger 2009
www.ginasthma.org
Global Initiative for Asthma

Asthma Management and Prevention Program: Summary

Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms

Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control
Global Initiative for Asthma

Asthma Management and Prevention Program: Summary A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered
Global Initiative for Asthma

http://www.ginasthma.org

Global Initiative for Asthma