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G lobal

INitiative for
A sthma
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
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
Mechanisms Underlying the
Definition of Asthma
Risk Factors
(for development of asthma)

INFLAMMATION

Airway
Hyperresponsiveness Airflow Obstruction

Risk Factors Symptoms


(for exacerbations)
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
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
Worldwide
Variation in
Prevalence of
Asthma
Symptoms

International Study of
Asthma and Allergies in
Children (ISAAC)

Lancet 1998;351:1225
Increasing Prevalence of Asthma in
Children/Adolescents

Finland
{1966
(Haahtela et al)
1989
Sweden
{1979
(Aberg et al)
1991
Japan
{1982
(Nakagomi et al)
1992
Scotland
{1982
(Rona et al)1992
UK
{1989
(Omran et al)
1994
USA
(NHIS) {1982
1992
New Zealand 1975
{1989
(Shaw et al)

Australia
{1982
(Peat et al)1992

0 5 10 15 20 25 30 35
Prevalence (%)
Trends in Prevalence of Asthma
By Age, U.S., 1985-1996
80 Rate/1,000 Persons
Age (years)
70
<18
60 18-44
45-64
50 65+
Total (All Ages)
40

30

20
85 86 87 88 89 90 91 92 93 94 95 96
Year
Hospitalization Rates for Asthma
by Age, U.S., 1974 - 1997

Rate/100,000 Persons
40
35 <15
30 15-44
45-64
25
65+
20
15
10
5
0
74 76 78 80 82 84 86 88 90 92 94 96

Year
Death Rates for Asthma
By Race, Sex, U.S., 1980-1998

Rate/100,000 Persons
5
Black Female

4
Black Male

3
White Female

White Male
1

0
1980 1985 1990 1995 2000
Year
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
Factors that Exacerbate Asthma

 Allergens
 Air Pollutants
 Respiratory infections
 Exercise and hyperventilation
 Weather changes
 Sulfur dioxide
 Food, additives, drugs
Risk Factors that Lead to
Asthma Development

Host Factors Environmental Factors


 Genetic predisposition  Indoor allergens
 Outdoor allergens
 Atopy
 Occupational sensitizers
 Airway hyper-
 Tobacco smoke
responsiveness
 Air Pollution
 Gender  Respiratory Infections
 Race/Ethnicity  Parasitic infections
 Socioeconomic factors
 Family size
 Diet and drugs
 Obesity
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
Asthma Diagnosis

 History and patterns of symptoms


 Physical examination
 Measurements of lung function
 Measurements of allergic status to
identify risk factors
Classification of Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment

Symptoms Nocturnal FEV1 or PEF


Symptoms
STEP 4 Continuous  60% predicted
Limited physical Frequent
Severe Variability > 30%
Persistent activity

STEP 3 Daily 60 - 80% predicted


> 1 time week
Moderate Attacks affect activity Variability > 30%
Persistent
STEP 2
> 2 times a month  80% predicted
> 1 time a week
Mild but < 1 time a day Variability 20 - 30%
Persistent

< 1 time a week


STEP 1  80% predicted
Asymptomatic  2 times a month
Intermittent and normal PEF Variability < 20%
between attacks
The presence of one feature of severity is sufficient to place patient in that category.
Six-Part Asthma Management
Program

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
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
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
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
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
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
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
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
Six-part Asthma Management Program
Factors Associated with
Non-Compliance in Asthma Care

Medication Usage Patient/Physician


 Difficulties associated  Misunderstanding/lack of
with inhalers information
 Complicated regimens  Underestimation of severity
 Fears about, or actual  Attitudes toward ill health
side effects
 Cultural factors
 Cost
 Poor communication
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
Typical Spirometric (FEV1)
Tracings
Volume

FEV1

Normal Subject

Asthmatic (After Bronchodilator)


Asthmatic (Before Bronchodilator)

1 2 3 4 5
Time (sec)

Note: Each FEV1 curve represents the highest of three repeat measurements
A Simple Index of PEF Variation

800 Highest PEF (670)

700
PEF (L/min)

600

500

Lowest morning PEF (570) Morning PEF


400 Evening PEF

300
0 7 14
Days

Minimum morning PEF ( % recent best): 570/670 = 85%


(From Reddel, H.K. et al. 1995)
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
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
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
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.
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
Part 4: Long-term Asthma Management

Pharmacologic Therapy

Reliever Medications:
 Rapid-acting inhaled β2-agonists
 Systemic glucocorticosteroids
 Anticholinergics
 Methylxanthines
 Short-acting oral β2-agonists
Estimated Comparative Daily Dosages
for Inhaled Glucocorticosteroids

Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
Adult Child Adult Child Adult Child

Beclomethasone- 200-500 100-250 500-1000 250-500 > 1000 > 500


CFC
Beclomethasone- 100-250 50-200 250-500 200-400 > 500 > 400
HFA
Budesonide-DPI 200-600 100-200 600-1000 200- 600 > 1000 > 600
Budesonide-Neb 250-500 500-1000 >1000

Flunisolde 500-1000 500 -750 1000-2000 750-1250 > 2000 > 1250

Fluticasone 100- 250 100-200 250- 500 200- 400 > 500 > 400
Mometasone 200- 400 400- 800 > 800
furoate
Triamcinolone 400- 1000 400-800 1000-2000 800-1200 > 2000 > 1200
acetonide
Part 4: Long-term Asthma Management
Stepwise Approach to Asthma
Therapy - Adults
Outcome: Asthma Control Outcome: Best
Possible Results

Controller:
 Daily inhaled
corticosteroid
plus
Controller:  When
 Daily long – asthma is
Controller:  Daily inhaled acting inhaled controlled,
Controller: Daily inhaled corticosteroid β2-agonist reduce
None plus  plus (if needed) therapy
corticosteroid
 Daily long- -Theophylline-SR
acting inhaled -Leukotriene
β2-agonist  Monitor
-Long-acting inhaled
β2- agonist
-Oral corticosteroid

Reliever: Rapid-acting inhaled β2-agonist prn


STEP 1: STEP 2: STEP 3: STEP 4: STEP Down
Intermittent Mild Persistent Moderate Severe
Persistent Persistent

Alternative controller and reliever medications may be considered (see text).


Recommended Asthma Medications
Step 1: Adults

Severity Daily Controller Other Options (in order


Medications of cost)
Step 1: • None • None
Intermittent

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.
Recommended Asthma Medications
Step 2: Adults

Severity Daily Controller Other Options (in order


Medications of cost)
Step 2: • Low-dose inhaled • Sustained-release
Mild glucocorticosteroid theophylline, or
Persistent • Cromone, or
• Leukotriene modifier

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.
Recommended Asthma Medications
Step 3: Adults

Severity Daily Controller Other Options (in order of cost)


Medications
Step 3: • Low- to medium-dose • Medium-dose inhaled glucocorticosteroid
Moderate inhaled glucocortico- plus sustained- release theophylline, or
persistent steroid plus long-acting • Medium-dose inhaled glucocorticosteroid
inhaled β2- agonist plus long-acting inhaled β2- agonist, or
• High-dose inhaled glucocorticosteroid, or
• Medium-dose inhaled glucocorticosteroid
plus leukotriene modifier

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.
Recommended Asthma Medications
Step 4: Adults
Severity Daily Controller Medications Other Options
Step 4 • High-dose inhaled glucocorticosteroid
Severe plus long-acting inhaled β2- agonist
persistent plus one or more of the following, if
needed:

- Sustained-release theophylline
- Leukotriene modifier
- Long-acting inhaled β2- agonist
- Oral glucocorticosteroid

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.
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.
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
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
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
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
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
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
Emergency Department Management
Acute Asthma
Initial Assessment
History, Physical Examination, PEF or FEV1

Initial Therapy
Bronchodilators; O2 if needed
Good Response
Incomplete/Poor Response Respiratory Failure

Observe for at Add Systemic Glucocorticosteroids


least 1 hour
Good Response Poor Response
If Stable,
Discharge to Discharge Admit to Hospital Admit to ICU
Home
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)
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
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
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
http://www.ginasthma.com
Part 4: Long-term Asthma Management
Stepwise Approach to Asthma
Therapy - Adults
Outcome: Asthma Control Outcome: Best
Possible Results

Controller:
 Daily inhaled
corticosteroid
Controller:  Daily long –  When
acting inhaled asthma is
Controller:  Daily inhaled β2-agonist controlled,
Controller: Daily inhaled corticosteroid reduce
 plus(if needed) therapy
None corticosteroid  Daily long-
acting inhaled -Theophylline-SR
β2-agonist -Leukotriene
 Monitor
-Long-acting inhaled
β2- agonist
-Oral corticosteroid

Reliever: Rapid-acting inhaled β2-agonist prn


STEP 1: STEP 2: STEP 3: STEP 4: STEP Down
Intermittent Mild Persistent Moderate Severe
Persistent Persistent

Alternative controller and reliever medications may be considered (see text).


Stepwise Approach to Asthma Therapy: Adults
Step 1: Intermittent Asthma

Daily Controller Reliever


Medications Medications

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
Stepwise Approach to Asthma Therapy: Adults
Step 2: Mild Persistent Asthma

Daily Controller Reliever


Medications Medications
Low-dose inhaled Rapid-acting inhaled 2-agonist
glucocorticosteroid for symptoms (but < 3-4 times/day)

Other options (order by cost): Other options:


 sustained-release theophylline, or  inhaled anticholinergic, or
 Cromone, or  short-acting oral 2-agonist, or
 leukotriene modifier  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 Reliever


Medications Medications
Low- to medium-dose inhaled glucocortico- Rapid-acting inhaled
steroid, plus long-acting inhaled 2-agonist 2-agonist for symptoms
(but < 3 - 4 times/day)
Other options (order by cost):
 Medium-dose inhaled glucocorticosteroid plus Other options:
sustained-release theophylline, or  inhaled anticholinergic or
 Medium-dose inhaled glucocorticosteroid plus long-  short-acting oral
acting inhaled β2- agonist, or 2-agonist or
 High-dose inhaled glucocorticosteroid, or
 short-acting theophylline
 Medium-dose inhaled glucocorticosteroid plus
leukotriene modifier

 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 Reliever


Medications Medications
High-dose inhaled glucocorticosteroid, Rapid-acting inhaled
plus long-acting inhaled β2agonist 2-agonist for symptoms
(but < 3-4 times/day)
plus one or more of the following, if
needed (order by cost): Other options:
 inhaled anticholinergic or
 sustained-release theophylline, or  short-acting oral
 leukotriene modifier or 2-agonist or
 oral glucocorticosteroid  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.