Professional Documents
Culture Documents
© Global
GINA 2015 Appendix Box A1-1; figure provided by Initiative for Asthma
R Beasley © Global Initiative for Asthma
Bangladesh
Slovenia Germany Ireland Saudi Arabia
Australia Yugoslavia Croatia
Brazil Canada
United States Austria Taiwan
Thailand Portugal
Philippines
Greece Malta
Moldova Mexico China
Syria Egypt South Africa
United Kingdom Hong Kong ROC Chile
Italy New Zealand Venezuela Cambodia
Argentina Israel
Lebanon Pakistan
Mongolia Japan
Poland Korea
GINA Assembly Netherlands
Switzerland Russia Macedonia Georgia
France
Turkey Czech Slovakia Belgium
Denmark
Republic
Romania Colombia Ukraine Singapore Spain
India
Sweden Albania Kyrgyzstan Vietnam
GINA resources - 2015
YES
Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
YES
Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?
YES
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
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
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?
FEV1
Asthma
(after BD)
Normal
Asthma
(before BD) Asthma
(after BD)
Asthma
(before BD)
1 2 3 4 5 Volume
Time (seconds)
Note: Each FEV1 represents the highest of
three reproducible measurements
Yes No
• Any night waking due to asthma?
Yes No
• Any night waking due to asthma?
Yes No
• Any activity limitation due to asthma?
Yes No
B. Risk factors for poor asthma outcomes
• Assess risk factors at diagnosis and periodically
• Measure FEV1 at start of treatment, after 3 to 6 months of treatment to record the patient’s
personal best, then periodically for ongoing risk assessment
GINA 2015 Box 2-2B (1/4) © Global Initiative for Asthma
Assessment of risk factors for poor asthma
outcomes
Risk factors for exacerbations include:
• Ever intubated for asthma
• Uncontrolled asthma symptoms
• Having ≥1 exacerbation in last 12 months
• Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)
• Incorrect inhaler technique and/or poor adherence
• Smoking
• Obesity, pregnancy, blood eosinophilia
Diagnosis
Demonstrate variable expiratory airflow limitation
Reconsider diagnosis if symptoms and lung function are discordant
• Frequent symptoms but normal FEV1: cardiac disease; lack of fitness?
• Few symptoms but low FEV1: poor perception; restriction of lifestyle?
Risk assessment
Low FEV1 is an independent predictor of exacerbation risk
Monitoring progress
Measure lung function at diagnosis, 3-6 months after starting
treatment
(to identify personal best), and then periodically
Consider long-term PEF monitoring for patients with severe asthma
or impaired perception of airflow limitation
Adjusting treatment?
Utility of lung function for adjusting treatment is limited by between-
visit variability of FEV1 (15% year-to-year)
How?
Asthma severity is assessed retrospectively from the level of
treatment required to control symptoms and exacerbations
When?
Assess asthma severity after patient has been on controller
treatment for several months
Severity is not static – it may change over months or years, or as
different treatments become available
Categories of asthma severity
Mild asthma: well-controlled with Steps 1 or 2 (as-needed SABA or
low dose ICS)
Moderate asthma: well-controlled with Step 3 (low-dose ICS/LABA)
Severe asthma: requires Step 4/5 (moderate or high dose
ICS/LABA ± add-on), or remains uncontrolled despite this treatment
Remove potential
risk factors. Assess and
manage comorbidities
Consider treatment
step-up
Refer to a specialist or
severe asthma clinic
Refer to a specialist or
severe asthma clinic
Consider treatment
step-up
Refer to a specialist or
severe asthma clinic
Refer to a specialist or
severe asthma clinic
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 2015, Box 3-3 (1/2) Provided by H Reddel © Global Initiative for Asthma
Choosing between controller options –
individual patient decisions
Decisions for individual patients
Use shared decision-making with the patient/parent/carer to discuss the following:
GINA 2015, Box 3-3 (2/2) Provided by H Reddel © Global Initiative for Asthma
Initial controller treatment for adults, adolescents
and children 6–11 years
Start controller treatment early
For best outcomes, initiate controller treatment as early as possible
after making the diagnosis of asthma
Indications for regular low-dose ICS - any of:
Asthma symptoms more than twice a month
Waking due to asthma more than once a month
Any asthma symptoms plus any risk factors for exacerbations
Consider starting at a higher step if:
Troublesome asthma symptoms on most days
Waking from asthma once or more a week, especially if any risk factors
for exacerbations
If initial asthma presentation is with an exacerbation:
Give a short course of oral steroids and start regular controller treatment
(e.g. high dose ICS or medium dose ICS/LABA, then step down)
Symptoms
Exacerbations
Asthma medications
Side-effects
Non-pharmacological strategies
Patient satisfaction
Treat modifiable risk factors
Lung function
STEP 5
STEP 4
Other
Consider low Leukotriene receptor antagonists (LTRA) Med/high dose ICS Add tiotropium# Add tiotropium#
controller dose ICS Low dose theophylline* Low dose ICS+LTRA High dose ICS Add low dose
options + LTRA OCS
(or + theoph*)
(or + theoph*)
• 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 stepping down if … symptoms controlled for 3 months + low risk for exacerbations.
Ceasing ICS is not advised.
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
*For children 6-11 years,
STEP 3 Refer for
PREFERRED STEP 1 STEP 2 theophylline is not
CONTROLLER add-on recommended, and preferred
CHOICE treatment Step 3 is medium dose ICS
Med/high
e.g.
ICS/LABA **For patients prescribed
Low dose anti-IgE BDP/formoterol or BUD/
Low dose ICS ICS/LABA* formoterol maintenance and
reliever therapy
Other Consider low Leukotriene receptor antagonists (LTRA) Med/high dose ICS Add tiotropium# Add
# Tiotropium by soft-mist
controller dose ICS Low dose theophylline* Low dose ICS+LTRA High dose ICS tiotropium#
+ LTRA Add low inhaler is indicated as add-on
options (or + theoph*)
(or + theoph*) dose OCS treatment for adults
(≥18 yrs) with a history of
As-needed short-acting beta2-agonist (SABA) As-needed SABA or
RELIEVER low dose ICS/formoterol** exacerbations
GINA 2015, Box 3-5 (2/8) (upper part) © Global Initiative for Asthma
Stepwise management – additional components
GINA 2015, Box 3-5 (3/8) (lower part) © Global Initiative for Asthma
Step 1 – as-needed inhaled short-acting
beta2-agonist (SABA)
STEP 5
STEP 4
*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of
exacerbations; it is not indicated in children <18 years.
GINA 2015, Box 3-5, Step 1 (4/8) © Global Initiative for Asthma
Step 1 – as-needed reliever inhaler
STEP 5
STEP 4
*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of
exacerbations; it is not indicated in children <18 years.
GINA 2015, Box 3-5, Step 2 (5/8) © Global Initiative for Asthma
Step 2 – Low dose controller + as-needed SABA
Preferred option: regular low dose ICS with as-needed inhaled SABA
Low dose ICS reduces symptoms and reduces risk of exacerbations and
asthma-related hospitalization and death
Other options
Leukotriene receptor antagonists (LTRA) with as-needed SABA
• Less effective than low dose ICS
• May be used for some patients with both asthma and allergic rhinitis, or if
patient will not use ICS
Combination low dose ICS/long-acting beta2-agonist (LABA)
with as-needed SABA
• Reduces symptoms and increases lung function compared with ICS
• More expensive, and does not further reduce exacerbations
Intermittent ICS with as-needed SABA for purely seasonal allergic asthma
with no interval symptoms
• Start ICS immediately symptoms commence, and continue for
4 weeks after pollen season ends
STEP 5
STEP 4
*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of
exacerbations; it is not indicated in children <18 years.
GINA 2015, Box 3-5, Step 3 (6/8) © Global Initiative for Asthma
Step 3 – one or two controllers + as-needed
inhaled reliever
Before considering step-up
Check inhaler technique and adherence, confirm diagnosis
Adults/adolescents: preferred options are either combination low dose
ICS/LABA maintenance with as-needed SABA, OR combination low dose
ICS/formoterol maintenance and reliever regimen*
Adding LABA reduces symptoms and exacerbations and increases FEV1, while
allowing lower dose of ICS
In at-risk patients, maintenance and reliever regimen significantly reduces
exacerbations with similar level of symptom control and lower ICS doses
compared with other regimens
Children 6-11 years: preferred option is medium dose ICS with
as-needed SABA
Other options
Adults/adolescents: Increase ICS dose or add LTRA or theophylline (less
effective than ICS/LABA)
Children 6-11 years – add LABA (similar effect as increasing ICS)
*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol
GINA 2015 © Global Initiative for Asthma
Step 4 – two or more controllers + as-needed
inhaled reliever UPDATED!
STEP 5
STEP 4
*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of
exacerbations; it is not indicated in children <18 years.
GINA 2015, Box 3-5, Step 4 (7/8) © Global Initiative for Asthma
Step 4 – two or more controllers + as-needed
inhaled reliever UPDATED!
*Approved only for low dose beclometasone/formoterol and low dose budesonide/formoterol
GINA 2015 © Global Initiative for Asthma
Step 5 – higher level care and/or add-on
treatment UPDATED!
STEP 5
STEP 4
*For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS
**For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy
# Tiotropium by soft-mist inhaler is indicated as add-on treatment for patients with a history of
exacerbations; it is not indicated in children <18 years.
GINA 2015, Box 3-5, Step 5 (8/8) © Global Initiative for Asthma
Step 5 – higher level care and/or add-on
treatment UPDATED!
Choose
• Choose an appropriate device before prescribing. Consider medication options,
arthritis, patient skills and cost. For ICS by pMDI, prescribe a spacer
• Avoid multiple different inhaler types if possible
Choose
• Choose an appropriate device before prescribing. Consider medication options,
arthritis, patient skills and cost. For ICS by pMDI, prescribe a spacer
• Avoid multiple different inhaler types if possible
Check
• Check technique at every opportunity – “Can you show me how you use your
inhaler at present?”
• Identify errors with a device-specific checklist
Choose
• Choose an appropriate device before prescribing. Consider medication options,
arthritis, patient skills and cost. For ICS by pMDI, prescribe a spacer
• Avoid multiple different inhaler types if possible
Check
• Check technique at every opportunity – “Can you show me how you use your
inhaler at present?”
• Identify errors with a device-specific checklist
Correct
• Give a physical demonstration to show how to use the inhaler correctly
• Check again (up to 2-3 times)
• Re-check inhaler technique frequently, as errors often recur within 4-6 weeks
Choose
• Choose an appropriate device before prescribing. Consider medication options,
arthritis, patient skills and cost. For ICS by pMDI, prescribe a spacer
• Avoid multiple different inhaler types if possible
Check
• Check technique at every opportunity – “Can you show me how you use your
inhaler at present?”
• Identify errors with a device-specific checklist
Correct
• Give a physical demonstration to show how to use the inhaler correctly
• Check again (up to 2-3 times)
• Re-check inhaler technique frequently, as errors often recur within 4-6 weeks
Confirm
• Can you demonstrate correct technique for the inhalers you prescribe?
• Brief inhaler technique training improves asthma control
Poor adherence:
Is very common: it is estimated that 50% of adults and children do not
take controller medications as prescribed
Contributes to uncontrolled asthma symptoms and risk of
exacerbations and asthma-related death
Contributory factors
Unintentional (e.g. forgetfulness, cost, confusion) and/or
Intentional (e.g. no perceived need, fear of side-effects, cultural
issues, cost)
How to identify patients with low adherence:
Ask an empathic question, e.g. “Do you find it easier to remember
your medication in the morning or the evening?”, or
“Would you say you are taking it 3 days a week, or less, or more?”
Check prescription date, label date and dose counter
Ask patient about their beliefs and concerns about the medication
Is it asthma?
START TREATMENT
SABA 4–10 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 1–2 mg/kg, max. 40 mg While waiting: give inhaled SABA
and ipratropium bromide, O2,
Controlled oxygen (if available): target
systemic corticosteroid
saturation 93–95% (children: 94-98%)
IMPROVING
FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (1–2 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?
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
Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA and
ipratropium bromide, O2, systemic
corticosteroid
Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?
START TREATMENT
TRANSFER TO ACUTE
SABA 4–10 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING While waiting: give inhaled SABA and
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg ipratropium bromide, O2, systemic
Controlled oxygen (if available): target corticosteroid
saturation 93–95% (children: 94-98%)
IMPROVING
IMPROVING
IMPROVING
FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (1–2 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?
NO
YES
Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation
NO
YES
Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation
UPDATED!
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 2015]
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 2015]
COPD
COPD is a common preventable and treatable disease, characterized by persistent
airflow limitation that is usually progressive and associated with enhanced chronic
inflammatory responses in the airways and the lungs to noxious particles or gases.
Exacerbations and comorbidities contribute to the overall severity in individual patients.
[GOLD 2015]
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 2015]
COPD
COPD is a common preventable and treatable disease, characterized by persistent
airflow limitation that is usually progressive and associated with enhanced chronic
inflammatory responses in the airways and the lungs to noxious particles or gases.
Exacerbations and comorbidities contribute to the overall severity in individual patients.
[GOLD 2015]
2. Syndromic diagnosis of
Lung function between
symptoms Normal Abnormal
3. Spirometry
Time course No worsening of symptoms over
time. Variation in symptoms either Symptoms slowly worsening over
seasonally, or from year to year time (progressive course over years)
May improve spontaneously or have Rapid-acting bronchodilator treatment
Lung function Record of variable airflow limitation Record of persistent airflow limitation
(spirometry or peak flow) (FEV1/FVC < 0.7 post-BD)
Lung function between Normal Abnormal
symptoms
Past history or family history Previous doctor diagnosis of asthma Previous doctor diagnosis of COPD,
chronic bronchitis or emphysema
Family history of asthma, and other
allergic conditions (allergic rhinitis or Heavy exposure to risk factor: tobacco
eczema) smoke, biomass fuels
Time course No worsening of symptoms over time. Symptoms slowly worsening over time
Variation in symptoms either (progressive course over years)
seasonally, or from year to year
Rapid-acting bronchodilator treatment
May improve spontaneously or have provides only limited relief
an immediate response to
bronchodilators or to ICS over weeks
NOTE: • These features best distinguish between asthma and COPD. • Several positive features (3 or more) for either asthma or COPD suggest
that diagnosis. • If there are a similar number for both asthma and COPD, consider diagnosis of ACOS
GINA
GINA 2015, Box 5-4
2014 © Global Initiative for Asthma
STEP 3 Marked
reversible airflow limitation FEV1/FVC < 0.7
PERFORM (pre-post bronchodilator) or other post-BD
SPIROMETRY proof of variable airflow limitation
Yes No
• Any activity limitation due to asthma?
(runs/plays less than other children,
tires easily during walks/playing)
Yes No
• Any night waking or night coughing
due to asthma?
Yes No
B. Risk factors for poor asthma outcomes
GINA 2015, Box 6-4A © Global Initiative for Asthma
Risk factors for poor asthma outcomes in
children ≤5 years
Risk factors for exacerbations in the next few months
• Uncontrolled asthma symptoms
• One or more severe exacerbation in previous year
• The start of the child’s usual ‘flare-up’ season (especially if autumn/fall)
• Exposures: tobacco smoke; indoor or outdoor air pollution; indoor allergens (e.g.
house dust mite, cockroach, pets, mold), especially in combination with viral infection
• Major psychological or socio-economic problems for child or family
• Poor adherence with controller medication, or incorrect inhaler technique
Diagnosis
Symptom control & risk factors
Inhaler technique & adherence
Parent preference
Symptoms
Exacerbations
Side-effects
Parent satisfaction
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
Symptoms
Exacerbations
Side-effects
Asthma medications
Parent satisfaction
Non-pharmacological strategies
Treat modifiable risk factors
STEP 4
STEP 3
PREFERRED STEP 1 STEP 2 Continue
CONTROLLER controller
CHOICE Double & refer for
‘low dose’ specialist
Daily low dose ICS ICS assessment
Other Leukotriene receptor antagonist (LTRA) Low dose ICS + LTRA Add LTRA
controller Intermittent ICS Inc. ICS
frequency
options Add intermitt ICS
CONSIDER Infrequent Symptom pattern consistent with asthma Asthma diagnosis, and Not well-
viral wheezing and asthma symptoms not well-controlled, or not well-controlled on controlled
THIS STEP FOR and no or few ≥3 exacerbations per year low dose ICS on double
CHILDREN interval ICS
WITH: symptoms Symptom pattern not consistent with asthma but
wheezing episodes occur frequently, e.g. every
First check diagnosis, inhaler skills,
6–8 weeks.
adherence, exposures
Give diagnostic trial for 3 months.
ALL CHILDREN
KEY
• Assess symptom control, future risk, comorbidities
ISSUES
• Self-management: education, inhaler skills, written asthma action plan, adherence
• Regular review: assess response, adverse events, establish minimal effective treatment
• (Where relevant): environmental control for smoke, allergens, indoor/outdoor air pollution
STEP 4
PREFERRED STEP 3
STEP 1 STEP 2 Continue
CONTROLLER
CHOICE controller
Double & refer for
‘low dose’ specialist
Daily low dose ICS ICS assessment
Other Leukotriene receptor antagonist (LTRA) Low dose ICS + LTRA Add LTRA
controller Intermittent ICS Inc. ICS
frequency
options Add intermitt ICS
Infrequent Symptom pattern consistent with asthma Asthma diagnosis, and Not well-
CONSIDER
viral wheezing and asthma symptoms not well-controlled, or not well-controlled on controlled
THIS STEP FOR
and no or ≥3 exacerbations per year low dose ICS on double
CHILDREN WITH:
few interval ICS
Symptom pattern not consistent with asthma but
symptoms First check diagnosis, inhaler skills,
wheezing episodes occur frequently, e.g. every
6–8 weeks. adherence, exposures
Give diagnostic trial for 3 months.
STEP 4
PREFERRED STEP 3
STEP 1 STEP 2 Continue
CONTROLLER
CHOICE controller
Double & refer for
‘low dose’ specialist
Daily low dose ICS ICS assessment
Other Leukotriene receptor antagonist (LTRA) Low dose ICS + LTRA Add LTRA
controller Intermittent ICS Inc. ICS
frequency
options Add intermitt ICS
CONSIDER Infrequent Symptom pattern consistent with asthma Asthma diagnosis, and Not well-
THIS STEP FOR viral wheezing and asthma symptoms not well-controlled, or not well-controlled on controlled
CHILDREN WITH: and no or ≥3 exacerbations per year low dose ICS on double
few interval ICS
Symptom pattern not consistent with asthma but
symptoms
wheezing episodes occur frequently, e.g. every First check diagnosis, inhaler skills,
6–8 weeks. adherence, exposures
Give diagnostic trial for 3 months.
STEP 4
PREFERRED STEP 3
STEP 1 STEP 2 Continue
CONTROLLER
CHOICE controller
Double & refer for
‘low dose’ specialist
Daily low dose ICS ICS assessment
Other Leukotriene receptor antagonist (LTRA) Low dose ICS + LTRA Add LTRA
Intermittent ICS Inc. ICS
controller frequency
options Add intermitt ICS
Infrequent Symptom pattern consistent with asthma Asthma diagnosis, and Not well-
CONSIDER viral wheezing and asthma symptoms not well-controlled, or not well-controlled on controlled
THIS STEP FOR and no or ≥3 exacerbations per year low dose ICS on double
CHILDREN WITH: few interval ICS
Symptom pattern not consistent with asthma but
symptoms
wheezing episodes occur frequently, e.g. every
6–8 weeks. First check diagnosis, inhaler skills,
Give diagnostic trial for 3 months. adherence, exposures
STEP 4
PREFERRED STEP 3
STEP 1 STEP 2 Continue
CONTROLLER
CHOICE controller
Double & refer for
‘low dose’ specialist
Daily low dose ICS ICS assessment
Other Leukotriene receptor antagonist (LTRA) Low dose ICS + LTRA Add LTRA
Intermittent ICS Inc. ICS
controller frequency
options Add intermitt ICS
Infrequent Symptom pattern consistent with asthma Asthma diagnosis, and Not well-
CONSIDER viral wheezing and asthma symptoms not well-controlled, or not well-controlled on controlled
THIS STEP FOR and no or ≥3 exacerbations per year low dose ICS on double
CHILDREN WITH: few interval ICS
Symptom pattern not consistent with asthma but
symptoms
wheezing episodes occur frequently, e.g. every
6–8 weeks. First check diagnosis, inhaler skills,
Give diagnostic trial for 3 months. adherence, exposures
STEP 4
PREFERRED STEP 3
STEP 1 STEP 2 Continue
CONTROLLER
CHOICE controller
Double & refer for
‘low dose’ specialist
Daily low dose ICS ICS assessment
Leukotriene receptor antagonist (LTRA) Low dose ICS + LTRA Add LTRA
Other
Intermittent ICS Inc. ICS
controller frequency
options Add intermitt ICS
Infrequent Symptom pattern consistent with asthma Asthma diagnosis, and Not well-
CONSIDER viral wheezing and asthma symptoms not well-controlled, or not well-controlled on controlled
THIS STEP FOR and no or ≥3 exacerbations per year low dose ICS on double
CHILDREN WITH: few interval ICS
Symptom pattern not consistent with asthma but
symptoms
wheezing episodes occur frequently, e.g. every
6–8 weeks. First check diagnosis, inhaler skills,
Give diagnostic trial for 3 months. adherence, exposures
GINA
GINA 2015, Box6-6
2015, Box 6-6 © Global Initiative for Asthma
Choosing an inhaler device for children ≤5 years
GINA
GINA 2015, Box6-7
2015, Box 6-6 © Global Initiative for Asthma
Primary care management of acute asthma or
wheezing in pre-schoolers
NEW!
IMPROVING
DISCHARGE/FOLLOW-UP PLANNING
Ensure that resources at home are adequate.
Reliever: continue as needed
Controller: consider need for, or adjustment of, regular controller
Check inhaler technique and adherence
Follow up: within 1-7 days
Provide and explain action plan
FOLLOW UP VISIT
Reliever: Reduce to as-needed
Controller: Continue or adjust depending on cause of exacerbation, and duration of need for extra salbutamol
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?
Schedule next follow up visit
*Normal respiratory rates (breaths/minute): 0-2 months: <60; 2-12 months: <50; 1-5 yrs: <40
GINA 2015, Box 6-10 © Global Initiative for Asthma
Initial management of asthma exacerbations
in children ≤5 years