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ASSESMENT OF ASTHMA AND

MANAGEMENT OF ASTHMA
WORSENING

NENI SAWITRI
Dr. Goenawan Partowidigdo
Pulmonary Hospital
Burden of asthma
Asthma is one of the most common chronic diseases worldwide
with an estimated 300 million affected individuals
Prevalence is increasing in many countries, especially in children
Asthma is a major cause of school and work absence
Health care expenditure on asthma is 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 due to
increasing prevalence of asthma
Poorly controlled asthma is expensive
However, investment in prevention medication is likely to yield cost
savings in emergency care

GINA 2017
Prevalence of asthma in children aged
13-14 years

Global
GINA 2017 Appendix Box A1-1; figure provided by Initiative for Asthma
R Beasley Global Initiative for Asthma
What is known about asthma?
Asthma is a common and potentially serious chronic
disease that can be controlled but not cured
Asthma causes symptoms such as wheezing, shortness of
breath, chest tightness and cough that vary over time in
their occurrence, frequency and intensity
Symptoms are associated with variable expiratory airflow,
i.e. difficulty breathing air out of the lungs due to
Bronchoconstriction (airway narrowing)
Airway wall thickening
Increased mucus
Symptoms may be triggered or worsened by factors such as
viral infections, allergens, tobacco smoke, exercise and
stress

GINA 2017
What is known about asthma?
Asthma can be effectively treated
When asthma is well-controlled, patients can
Avoid troublesome symptoms during the 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 (also called exacerbations,
or severe attacks)

GINA 2017
Definition of asthma

Asthma is a heterogeneous disease, usually characterized by


chronic airway inflammation.

It is defined by the history of respiratory symptoms such as


wheeze, shortness of breath, chest tightness and cough that vary
over time and in intensity, together with variable expiratory
airflow limitation.

GINA 2017
Diagnosis of asthma
The diagnosis of asthma should be based on:
A history of characteristic symptom patterns
Evidence of variable airflow limitation, from
bronchodilator reversibility testing or other tests
Document evidence for the diagnosis in the patients
notes, preferably before starting controller treatment
It is often more difficult to confirm the diagnosis after
treatment has been started
Asthma is usually characterized by airway inflammation
and airway hyperresponsiveness, but these are not
necessary or sufficient to make the diagnosis of
asthma.

GINA 2017
Patient with
respiratory symptoms
Are the symptoms typical of asthma?

YES

Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?

YES

Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?

YES

Treat for ASTHMA

GINA 2017, Box 1-1 (1/4) Global Initiative for Asthma


Patient with
respiratory symptoms
Are the symptoms typical of asthma?

NO
YES

Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
NO alternative diagnoses
YES Alternative diagnosis confirmed?

Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?

YES YES

Treat for ASTHMA Treat for alternative diagnosis

GINA 2017, Box 1-1 (2/4) Global Initiative for Asthma


Patient with
respiratory symptoms
Are the symptoms typical of asthma?

NO
YES

Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
NO alternative diagnoses
YES Alternative diagnosis confirmed?

Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?

Repeat on another
NO
occasion or arrange
NO
YES other tests
Confirms asthma diagnosis?

YES NO YES

Consider trial of treatment for


most likely diagnosis, or refer
for further investigations

Treat for ASTHMA Treat for alternative diagnosis

GINA 2017, Box 1-1 (3/4) Global Initiative for Asthma


Patient with
respiratory symptoms
Are the symptoms typical of asthma?

NO
YES

Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
NO alternative diagnoses
Clinical urgency, and
YES Alternative diagnosis confirmed?
other diagnoses unlikely

Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?

Repeat on another
NO
occasion or arrange
NO
YES other tests
Confirms asthma diagnosis?

Empiric treatment with YES NO YES


ICS and prn SABA
Review response
Consider trial of treatment for
Diagnostic testing most likely diagnosis, or refer
within 1-3 months for further investigations

Treat for ASTHMA Treat for alternative diagnosis

GINA 2017, Box 1-1 (4/4) Global Initiative for Asthma


Patient with
respiratory symptoms
Are the symptoms typical of asthma?

YES

Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?

YES

Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?

YES

Treat for ASTHMA

GINA 2017, Box 1-1 (1/4) Global Initiative for Asthma


Patient with
respiratory symptoms
Are the symptoms typical of asthma?

NO
YES

Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
NO alternative diagnoses
YES Alternative diagnosis confirmed?

Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?

YES YES

Treat for ASTHMA Treat for alternative diagnosis

GINA 2017, Box 1-1 (2/4) Global Initiative for Asthma


Patient with
respiratory symptoms
Are the symptoms typical of asthma?

NO
YES

Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
NO alternative diagnoses
YES Alternative diagnosis confirmed?

Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?

Repeat on another
NO
occasion or arrange
NO
YES other tests
Confirms asthma diagnosis?

YES NO YES

Consider trial of treatment for


most likely diagnosis, or refer
for further investigations

Treat for ASTHMA Treat for alternative diagnosis

GINA 2017, Box 1-1 (3/4) Global Initiative for Asthma


Patient with
respiratory symptoms
Are the symptoms typical of asthma?

NO
YES

Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
NO alternative diagnoses
Clinical urgency, and
YES Alternative diagnosis confirmed?
other diagnoses unlikely

Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?

Repeat on another
NO
occasion or arrange
NO
YES other tests
Confirms asthma diagnosis?

Empiric treatment with YES NO YES


ICS and prn SABA
Review response
Consider trial of treatment for
Diagnostic testing most likely diagnosis, or refer
within 1-3 months for further investigations

Treat for ASTHMA Treat for alternative diagnosis

GINA 2017, Box 1-1 (4/4) Global Initiative for Asthma


The control-based asthma
management cycle
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference

Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function

Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors

GINA 2017, Box 3-2


Stepwise approach to control
asthma symptoms UPDATED
2017

and reduce risk


Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference

Symptoms
Exacerbations
Asthma medications
Side-effects
Non-pharmacological strategies
Patient satisfaction
Treat modifiable risk factors
Lung function

STEP 5

STEP 4
STEP 3 Refer for add-
PREFERRED STEP 1 STEP 2
CONTROLLER on treatment
e.g.
CHOICE Med/high tiotropium,*
anti-IgE,
ICS/LABA
Low dose anti-IL5*

Low dose ICS ICS/LABA**

Other Med/high dose ICS Add tiotropium* Add low dose


Consider low Leukotriene receptor antagonists (LTRA)
controller dose ICS Low dose theophylline* Low dose ICS+LTRA High dose ICS OCS
options (or + theoph*) + LTRA
(or + theoph*)

RELIEVER As-needed short-acting beta2-agonist (SABA) As-needed SABA or


low dose ICS/formoterol#

Provide guided self-management education (self-monitoring + written action plan + regular review)
REMEMBER
Treat modifiable risk factors and comorbidities, e.g. smoking, obesity, anxiety
TO...
Advise about non-pharmacological therapies and strategies, e.g. physical activity, weight loss, avoidance of
sensitizers where appropriate
Consider stepping up if uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler
technique and adherence first
Consider adding SLIT in adult HDM-sensitive patients with allergic rhinitis who have exacerbations despite
ICS treatment, provided FEV1 is >70% predicted
Consider stepping down if symptoms controlled for 3 months + low risk for exacerbations.
Ceasing ICS is not advised.

GINA 2017, Box 3-5 (1/8) Global Initiative for Asthma


Stepwise management - UPDATED
2017

pharmacotherapy Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference

Symptoms
Exacerbations
Side-effects Asthma medications
Patient satisfaction Non-pharmacological strategies
Lung function Treat modifiable risk factors

STEP 5

STEP 4

STEP 3 Refer for *Not for children <12 years


PREFERRED STEP 1 STEP 2 add-on **For children 6-11 years, the
CONTROLLER treatment preferred Step 3 treatment is
CHOICE e.g.
Med/high tiotropium,* medium dose ICS
ICS/LABA anti-IgE,
#For patients prescribed
Low dose anti-IL5*
Low dose ICS BDP/formoterol or BUD/
ICS/LABA**
formoterol maintenance and
reliever therapy
Other Consider low Leukotriene receptor antagonists (LTRA) Med/high dose ICS Add tiotropium* Add low
controller dose ICS Low dose theophylline* Low dose ICS+LTRA High dose ICS dose OCS Tiotropium by mist inhaler is
+ LTRA
options (or + theoph*)
(or + theoph*)
an add-on treatment for
patients 12 years with a
As-needed short-acting beta2-agonist (SABA) As-needed SABA or history of exacerbations
RELIEVER
low dose ICS/formoterol#

GINA 2017, Box 3-5 (2/8) (upper part)


How to distinguish between
uncontrolled
Watch patient using their Compare inhaler technique with a device-

and severe asthma


inhaler. Discuss adherence
and barriers to use
specific checklist, and correct errors;
recheck frequently. Have an empathic
discussion about barriers to adherence.

Remove potential
risk factors. Assess and
manage comorbidities

Consider treatment
step-up

Refer to a specialist or
severe asthma clinic

GINA 2017, Box 2-4 (1/5) Global Initiative for Asthma


How to distinguish between
uncontrolled
Watch patient using their Compare inhaler technique with a device-

and severe asthma


inhaler. Discuss adherence
and barriers to use
specific checklist, and correct errors;
recheck frequently. Have an empathic
discussion about barriers to adherence.

If lung function normal during symptoms,


Confirm the diagnosis consider halving ICS dose and repeating
of asthma lung function after 23 weeks.

Refer to a specialist or
severe asthma clinic

GINA 2017, Box 2-4 (2/5) Global Initiative for Asthma


How to distinguish between
uncontrolled
Watch patient using their Compare inhaler technique with a device-

and severe asthma


inhaler. Discuss adherence
and barriers to use
specific checklist, and correct errors;
recheck frequently. Have an empathic
discussion about barriers to adherence.

If lung function normal during symptoms,


Confirm the diagnosis consider halving ICS dose and repeating
of asthma lung function after 23 weeks.

Remove potential Check for risk factors or inducers such as


smoking, beta-blockers, NSAIDs, allergen
risk factors. Assess and exposure. Check for comorbidities such as
manage comorbidities rhinitis, obesity, GERD, depression/anxiety.

Consider treatment
step-up

Refer to a specialist or
severe asthma clinic

GINA 2017, Box 2-4 (3/5) Global Initiative for Asthma


How to distinguish between
uncontrolled
Watch patient using their Compare inhaler technique with a device-

and severe asthma


inhaler. Discuss adherence
and barriers to use
specific checklist, and correct errors;
recheck frequently. Have an empathic
discussion about barriers to adherence.

If lung function normal during symptoms,


Confirm the diagnosis consider halving ICS dose and repeating
of asthma lung function after 23 weeks.

Remove potential Check for risk factors or inducers such as


smoking, beta-blockers, NSAIDs, allergen
risk factors. Assess and exposure. Check for comorbidities such as
manage comorbidities rhinitis, obesity, GERD, depression/anxiety.

Consider step up to next treatment level.


Consider treatment Use shared decision-making, and balance
step-up potential benefits and risks.

Refer to a specialist or
severe asthma clinic

GINA 2017, Box 2-4 (4/5) Global Initiative for Asthma


How to distinguish between
uncontrolled
Watch patient using their Compare inhaler technique with a device-

and severe asthma


inhaler. Discuss adherence
and barriers to use
specific checklist, and correct errors;
recheck frequently. Have an empathic
discussion about barriers to adherence.

If lung function normal during symptoms,


Confirm the diagnosis consider halving ICS dose and repeating
of asthma lung function after 23 weeks.

Remove potential Check for risk factors or inducers such as


smoking, beta-blockers, NSAIDs, allergen
risk factors. Assess and exposure. Check for comorbidities such as
manage comorbidities rhinitis, obesity, GERD, depression/anxiety.

Consider step up to next treatment level.


Consider treatment Use shared decision-making, and balance
step-up potential benefits and risks.

If asthma still uncontrolled after 36 months


Refer to a specialist or on Step 4 treatment, refer for expert advice.
severe asthma clinic Refer earlier if asthma symptoms severe,
or doubts about diagnosis.

GINA 2017, Box 2-4 (5/5) Global Initiative for Asthma


Kenapa perburukan asma
terjadi?
Tingginya penggunaan terapi PELEGA dan rendahnya
penggunaan ICS

Undertreated and
poorly controlled

1. Asthma worsenings: Approaches to prevention and management from the Asthma Worsenings Working Group, Can Respir J Vol 15 Suppl B November/December 2008
Pasien meningkatkan dosis SABA pada awal gejala, tetapi
terlambat dan hanya sedikit menaikkan ICS3

Rata-rata jumlah Rata-rata jumlah


ICS & LABA
inhalasi SABA per hari inhalasi ICS per hari
ICS no LABA
5 5 Salmeterol/Fluticasone
Bedesonide/formoterol
Early No early
4 4 adjustmen
adjustmen
t t
3 3

2 2

1 4-fold 1 2-fold
increase increase
at worst at worst
0 0
When Signs/ At worst Recovery When Signs/ At worst Recovery
well warnings well warnings

Adapted from Partridge 2006 Study INSPIRE 3. Partridge MR, et al. BMC Pulm Med 2006;6:13.
Penggunaan SABA pada asma
2-agonis inhalasi kerja singkat yang digunakan
untuk melegakan gejala sudah dipakai luas di
seluruh dunia
Penggunaan SABA yang regular (terus menerus)
telah terbukti:
Memperburuk kontrol asma
(Sears et al. Lancet 1990;336:1391-6)
Meningkatan inflamasi saluran napas
(Gauvreau GM, et al. AJRCCM 1997;156:1738-45)

Penggunaan SABA yang berlebihan dikaitkan


dengan peningkatan mortalitas asma (Suissa S et al. AJRCCM
1994;149:604-10)
Courtesy of Paul OByrne, ERS 2013
Apa akibatnya?
Eksaserbasi dan perburukan dapat menurunkan
fungsi faal paru

1. Asthma worsenings: Approaches to prevention and management from the Asthma Worsenings Working Group, Can Respir J Vol 15 Suppl B November/December
2008
Pasien dengan penggunaan SABA yang tidak tepat dan ICS yang
rendah cenderung lebih beresiko dirawat di RS dan UGS1

1. Asthma worsenings: Approaches to prevention and management from the Asthma Worsenings Working Group, Can Respir J Vol 15 Suppl B November/December 2008
Pasien dengan dosis tinggi SABA biaya pengobatan 3x lebih tinggi
daripada pasien asma pada umumnya4

3x lebih tinggi

The analysis was conducted during the 12 months of 1993 in four health maintenance organizations with approximately 673,000 members. Health care
costs were identified in asthmatic patients, age 7 years and over, who used high doses of inhaled beta-adrenergic agonists, defined as more than 8 puffs
per day.

4. Stempel DA, Durcannin-Robbins JF, Hedblom EC, Woolf R, Sturm LL, Stempl AB. Drug utilization evaluation identifies costs associated with high use of beta-adrenergic
agonists. Ann Allergy Asthma Immunol 1996;76:153-58.
Pasien dengan SABA yang berlebihan menunjukkan resiko
kunjungan UGD, hospitalisasi, dan dosis oral steroid LEBIH
tinggi daripada pasien non-SABA5
P<0.001

5. Silver, Harris, MD., Relationship Between Short-Acting b2-Adrenergic Agonist Use and Healthcare Costs. The American Journal of managed care, 2011, Vol. 17, No. 1.
Rationale for change in
recommendation about controller
For the therapy in
last 10 years, most asthma
guidelines action
recommended plans
treating
worsening asthma with SABA alone until OCS were needed, but ...
Most exacerbations are characterised by increased inflammation
Most evidence for self-management involved doubling ICS dose
Outcomes were consistently better if the action plan prescribed both
increased ICS, and OCS
Lack of generalisability of placebo-controlled RCTs of doubling ICS
Participants were required to be highly adherent
Study inhalers were not started, on average, until symptoms and airflow
limitation had been worsening for 4-5 days.
Severe exacerbations are reduced by short-term treatment with
Quadrupled dose of ICS
Quadrupled dose of budesonide/formoterol
Early small increase in ICS/formoterol (maintenance & reliever regimen)
Adherence by community patients is poor
Patients commonly take only 25-35% of prescribed controller dose
Patients often delay seeking care for fear of being given OCS
GINA 2017
Definition and terminology
A flare-up or exacerbation is an acute or sub-acute worsening
of symptoms and lung function compared with the patients usual
status
Terminology
Flare-up is the preferred term for discussion with patients
Exacerbation is a difficult term for patients
Attack has highly variable meanings for patients and clinicians
Episode does not convey clinical urgency
Consider management of worsening asthma as a continuum
Self-management with a written asthma action plan
Management in primary care
Management in the emergency department and hospital
Follow-up after any exacerbation

GINA 2017
Managing exacerbations in primary care
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation

Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?

MILD or MODERATE SEVERE


Talks in phrases, prefers
LIFE-THREATENING
Talks in words, sits hunched
sitting to lying, not agitated forwards, agitated Drowsy, confused
Respiratory rate increased Respiratory rate >30/min or silent chest
Accessory muscles not used Accessory muscles in use
Pulse rate 100120 bpm Pulse rate >120 bpm
O2 saturation (on air) 9095% O2 saturation (on air) <90%
PEF >50% predicted or best PEF 50% predicted or best URGENT

START TREATMENT
SABA 410 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING
Prednisolone: adults 1 mg/kg, max.
50 mg, children 12 mg/kg, max. 40 mg While waiting: give inhaled
SABA and ipratropium bromide,
Controlled oxygen (if available): target O2, systemic corticosteroid
saturation 9395% (children: 94-98%)

CONTINUE TREATMENT with SABA as needed


WORSENING
ASSESS RESPONSE AT 1 HOUR (or earlier)

IMPROVING

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE


Symptoms improved, not needing SABA Reliever: continue as needed
PEF improving, and >60-80% of personal Controller: start, or step up. Check inhaler
best or predicted technique, adherence
Oxygen saturation >94% room air Prednisolone: continue, usually for 57 days
(3-5 days for children)
Resources at home adequate
Follow up: within 27 days

FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (12 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?

GINA 2017, Box 4-3 (1/7)


PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation

Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?

LIFE-THREATENING
Drowsy, confused
or silent chest

URGENT

TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA
and ipratropium bromide, O2,
systemic corticosteroid

GINA 2017, Box 4-3 (2/7) Global Initiative for Asthma


PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation

Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?

MILD or MODERATE SEVERE


Talks in phrases, prefers Talks in words, sits hunched LIFE-THREATENING
sitting to lying, not agitated forwards, agitated Drowsy, confused
Respiratory rate increased Respiratory rate >30/min or silent chest
Accessory muscles not used Accessory muscles in use
Pulse rate 100120 bpm Pulse rate >120 bpm
O2 saturation (on air) 9095% O2 saturation (on air) <90%
PEF >50% predicted or best PEF 50% predicted or best URGENT

TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA
and ipratropium bromide, O2,
systemic corticosteroid

GINA 2017, Box 4-3 (3/7) Global Initiative for Asthma


PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation

Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?

MILD or MODERATE SEVERE


Talks in phrases, prefers Talks in words, sits hunched LIFE-THREATENING
sitting to lying, not agitated forwards, agitated Drowsy, confused
Respiratory rate increased Respiratory rate >30/min or silent chest
Accessory muscles not used Accessory muscles in use
Pulse rate 100120 bpm Pulse rate >120 bpm
O2 saturation (on air) 9095% O2 saturation (on air) <90%
PEF >50% predicted or best PEF 50% predicted or best URGENT

START TREATMENT
TRANSFER TO ACUTE
SABA 410 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING While waiting: give inhaled SABA
Prednisolone: adults 1 mg/kg, max.
50 mg, children 12 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid
saturation 9395% (children: 94-98%)

GINA 2017, Box 4-3 (4/7) Global Initiative for Asthma


START TREATMENT
SABA 410 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
Prednisolone: adults 1 mg/kg, max. WORSENING
While waiting: give inhaled SABA
50 mg, children 12 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid
saturation 9395% (children: 94-98%)

CONTINUE TREATMENT with SABA as needed


WORSENING
ASSESS RESPONSE AT 1 HOUR (or earlier)

IMPROVING

ASSESS FOR DISCHARGE


Symptoms improved, not needing SABA
PEF improving, and >60-80% of personal
best or predicted
Oxygen saturation >94% room air
Resources at home adequate

GINA 2017, Box 4-3 (5/7) Global Initiative for Asthma


START TREATMENT
SABA 410 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
Prednisolone: adults 1 mg/kg, max. WORSENING
While waiting: give inhaled SABA
50 mg, children 12 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid
saturation 9395% (children: 94-98%)

CONTINUE TREATMENT with SABA as needed


WORSENING
ASSESS RESPONSE AT 1 HOUR (or earlier)

IMPROVING

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE


Symptoms improved, not needing SABA Reliever: continue as needed
PEF improving, and >60-80% of personal Controller: start, or step up. Check inhaler technique,
best or predicted adherence
Oxygen saturation >94% room air Prednisolone: continue, usually for 57 days
(3-5 days for children)
Resources at home adequate
Follow up: within 27 days

GINA 2017, Box 4-3 (6/7) Global Initiative for Asthma


START TREATMENT
SABA 410 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
Prednisolone: adults 1 mg/kg, max. WORSENING
While waiting: give inhaled SABA
50 mg, children 12 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid
saturation 9395% (children: 94-98%)

CONTINUE TREATMENT with SABA as needed


WORSENING
ASSESS RESPONSE AT 1 HOUR (or earlier)

IMPROVING

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE


Symptoms improved, not needing SABA Reliever: continue as needed
PEF improving, and >60-80% of personal Controller: start, or step up. Check inhaler technique,
best or predicted adherence
Oxygen saturation >94% room air Prednisolone: continue, usually for 57 days
(3-5 days for children)
Resources at home adequate
Follow up: within 27 days

FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (12 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?

GINA 2017, Box 4-3 (7/7) Global Initiative for Asthma


Managing exacerbations in acute care settings

INITIAL ASSESSMENT Are any of the following present?


A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest

NO
YES

Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation

MILD or MODERATE SEVERE

Talks in phrases Talks in words


Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
Pulse rate 100120 bpm Pulse rate >120 bpm
O2 saturation (on air) 9095% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF 50% predicted or best

Short-acting beta2-agonists Short-acting beta2-agonists


Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 9395% (children 94-98%) saturation 9395% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS

If continuing deterioration, treat as


severe and re-aassess for ICU

ASSESS CLINICAL PROGRESS FREQUENTLY


MEASURE LUNG FUNCTION
in all patients one hour after initial treatment

FEV1 or PEF 60-80% of predicted or FEV1 or PEF <60% of predicted or


personal best and symptoms improved personal best,or lack of clinical response
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning and reassess frequently

GINA 2017, Box 4-4 (1/4)


INITIAL ASSESSMENT Are any of the following present?
A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest

NO
YES

Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation

MILD or MODERATE SEVERE


Talks in phrases Talks in words
Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
Pulse rate 100120 bpm Pulse rate >120 bpm
O2 saturation (on air) 9095% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF 50% predicted or best

GINA 2017, Box 4-4 (2/4) Global Initiative for Asthma


MILD or MODERATE SEVERE
Talks in phrases Talks in words
Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
Pulse rate 100120 bpm Pulse rate >120 bpm
O2 saturation (on air) 9095% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF 50% predicted or best

Short-acting beta2-agonists Short-acting beta2-agonists


Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 9395% (children 94-98%) saturation 9395% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS

GINA 2017, Box 4-4 (3/4)


Short-acting beta2-agonists Short-acting beta2-agonists
Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 9395% (children 94-98%) saturation 9395% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS

If continuing deterioration, treat as


severe and re-assess for ICU

ASSESS CLINICAL PROGRESS FREQUENTLY


MEASURE LUNG FUNCTION
in all patients one hour after initial treatment

FEV1 or PEF <60% of predicted or


FEV1 or PEF 60-80% of predicted or
personal best,or lack of clinical response
personal best and symptoms improved
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning
and reassess frequently

GINA 2017, Box 4-4 (4/4) Global Initiative for Asthma


Follow-up after an exacerbation
Follow up all patients regularly after an exacerbation, until
symptoms and lung function return to normal
Patients are at increased risk during recovery from an exacerbation
The opportunity
Exacerbations often represent failures in chronic asthma care,
and they provide opportunities to review the patients asthma
management
At follow-up visit(s), check:
The patients understanding of the cause of the flare-up
Modifiable risk factors, e.g. smoking
Adherence with medications, and understanding of their purpose
Inhaler technique skills
Written asthma action plan

GINA 2017, Box 4-5


TERIMA KASIH