Global Initiative for

Asthma 2022
Miranda, Peter
3rd year
Internal Medicine Resident
 ASTHMA
● Asthma is a common respiratory
disease affecting 1-18% of the
population in different countries.
● Heterogeneous disease characterized by
chronic airway inflammation.
● Usually presents with history of
respiratory symptoms; shortness of
breath, chest tightness and cough - may
vary over time and intensity.
 Asthma Phenotypes
● Allergic Asthma – most common
○ Childhood associated with past and/or family history of allergic disease;
eczema, allergic rhinitis or food and drug allergy
○ Increase sputum production – eosinophilic airway inflammation
○ Respond to ICS
● Non-allergic asthma
○ Neutrophilic, eosinophilic, contain inflammatory cells
○ Less short term response to ICS
 Asthma Phenotypes

● Adult-onset
○ Present first time in adult life
○ Non allergic
○ occupational exposure needs to be ruled out
○ Require higher doses of ICS or relatively refractory to corticosteroid treatment
● Asthma with persistent airflow limitation
○ Long standing asthma develop airflow limitation
○ May be persistent or incompletely reversible
● Asthma with Obesity
○ Have prominent respiratory symptoms and little eosinophilic airway inflammation
Making the initial
diagnosis
Diagnosis of asthma Box 1-2

Box 1-3

Next
© Global Initiative for Asthma,
GINA 2022, Box 1-1
Patients with respiratory symptoms

Not on controller On controller

treatment medication
Patients not on controller treatment

• History of Variable Respiratory

symptoms
• Confirmed Variable Expiratory
Airflow limitation
History of variable Respiratory
Symptoms
Symptoms support
Feature
Asthma
more than one type of respiratory
Wheeze
symptom
occur variably over time and vary
Shortness of breath in intensity - worse at night or on
waking
• triggered by exercise,
Chest tightness
laughter allergens, cold air
• appear or worsen with
Cough
viral infections
 Confirmed Variable Expiratory Airflow Limitation
When FEV1 reduced
Documented Expiratory airflow
FEV1/FVC reduced compared to lower
limitation
limit NV >0.75-0.80
Documented Excessive variability in lung
function
A. Positive Bronchodilator (PD)
increase FEV1 >12% and >200ML
responsiveness
B. Excessive Variability twice daily PEF
average daily diurnal PEF variability <10%
over 2 weeks

C. Significant increase in lung increase in FEV1 of 10% and 200mL

function after 4 weeks of anti- from baseline after 4 weeks of
inflammatory treatment treatment, outside respiratory infections
 Detailed History/Examination
History Physical Exam
Respiratory symptoms in
often normal
Childhood
History of allergic rhinitis or
expiratory wheezing (rhonchi)
eczema
Family history of asthma or
allergy
Patient already taking controller
treatment
 Assessment of Asthma
1. Assessment of asthma control = and future risk of adverse outcomes

• Assess symptom control over then last four weeks

• Risk factors for exacerbations, persistent airflow limitation or side effects
• Measure lung function
• start of treatment (3-6 months)
• periodically (once at least every 1-2 years)

2. Assess treatment issues

● Patient's current treatment step

● Watch inhaler technique
● Check asthma written action plan

3. Assess comorbidities
Assess the level of asthma control
• In the past 4 weeks, has the patient had
• Daytime symptoms more than twice/week
• any night awakening due to asthma
• SABA reliever for symptoms more than
twice/week
• any activity limitation due to asthma
Assess the level of asthma control
• Risk Factors for poor asthma outcomes
• Medications
• other medical conditions
• Exposures
• Context
• Lung Function
• Hx of intubation or ICU admission for asthma
• >1 severe exacerbation in the last 12 months
 Lung function in assessing Asthma
1. Low FEV1 percent predicted

● >60% predicted patient's at risk for asthma exacerbations, regardless of

symptom level
● risk factor for lung decline

2. Normal or near normal FEV1 - in a patient with frequent respiratory

symptoms

● Alternative diagnosis; cardiac disease, cough caused by post nasal drip,

GERD

3. Persistent bronchodilator responsiveness

● Significant bronchodilator responsiveness (increase in FEV1>12%

and>200mL from baseline) in patients taking controller treatment or taken
SABA within 4 hours or LABA within 24 hours suggest uncontrolled asthma
 Differential Diagnosis

Age 12-39
Congenital heart disease
Bronchiectasis
Age 40+ Inhaled foreign body

COPD
Cardiac failure
Medical related cough All ages
Tuberculosis
 Assessing Asthma severity
Severe asthma
● Uncontrolled despite
Moderate asthma
optimized treatment with high ● Asthma controlled with low
dose ICS-LABA or requires or medium dose ICS-LABA
high dose ICS-LABA
● Inadequate or inappropriate
treatment
Mild asthma
● Well controlled with as
needed ICS-formoterol or
with low dose ICS plus as-
needed SABA
Treatment
Long term goals
● To achieve good control of symptoms and
maintain normal activity level
● To minimize the risk of asthma related death,
exacerbations persistent airflow limitation and side
effects
 Personalized Asthma Control

Symptom Control Risk Reduction

● Modifiable risk factors
● Pharmacological for exacerbations
● Non-Pharmacologic ● Other outcomes and
comorbidities
 Asthma control

Review Assess

Adjust
 Review
• Symptoms
• Exacerbations
• Side effects
• Lung function
• Patient satisfaction
 Assess
• Confirmation of diagnosis,
if necessary
• Symptom control and
modifiable risk factors
• Comorbities
• Inhaler technique
• Patient preferences or
goals
 Adjust
• Treatment of modifiable
risk factors
• Non pharmacologic
strategies
• Asthma medications (adjust
down/up between tracks)
• Education and skills training
 Asthma
medication
 Asthma medication

Controller Reliever
Controller
● Contain ICS
○ Used to reduce airway
inflammation
○ Control symptoms
○ Reduce future risks
● The dose and regimen should be
optimized to minimize the risk of
medication side effects
Reliever

● As needed relief for breakthrough

symptoms
○ Worsening asthma or exacerbations
● Short term prevention of exercise induced
bronchoconstriction
● As needed, low-dose ICS-formoterol
● As needed, SABA
○ Dispensing of three or more 200-dose
canisters in a year - increases the risk
of asthma exacerbations
Starting treatment
 Before starting controller treatment
● Record evidence for diagnosing
asthma
● Record patient's level of symptom
control and risk factors
● Consider factors influencing
choice between treatment options
● Ensure patient can use inhaler
properly
 Assess

Confirmation of
Symptom control and
diagnosis
modifiable risk factors

Inhaler technique and

Comorbities
adherence
 Symptoms on most
days, waking up at
Medium dose ICS-
night ≥ once a week
LABA Step 4
with low lung
function

Symptoms on most Low dose ICS-LABA

days, waking up at OR medium dose Step 3
night ≥ once a week ICS OR very low
dose MART

Symptoms
twice a Step 2
Daily dose ICS
month or
more
 Step 1-2
● Initial treatment or Step down for patients
with well controlled regular ICS
● Low dose ICS-Formoterol
● Controller and reliever
● Prevents severe exacerbations in
patients with mild symptoms
● Regular low dose ICS plus SABA
● Poor adherence to ICS
● Risk for SABA only treatment
● Leading to exacerbations
 Use of ICS- Formoterol
● Usual dose of Budesonide- Formoterol as single
inhalation 200/6 mcg (delivered dose 160/4.5mcg) for
symptom relief with a maximum recommended dose
of 72 mcg Formoterol (54mcg delivered dose)
● Rinsing of the mouth is generally not needed
Step 3
 Step 3
● Patients with ≥ 1 exacerbation in the
previous year
● Low dose ICS-formoterol as maintenance
and reliever symptom relief
○ Budesonide-Formoterol maximum
recommended dose of 72 mcg (54mcg
delivered dose)
○ Beclomethasome-formoterol maximum
recommended dose of 48 mcg (36 mcg
delivered dose)
STEP 4
 Step 4
● Patients with uncontrolled asthma on low
dose ICS-LABA
○ Despite good adherence and correct
inhaler technique
● Medium dose ICS-LABA as maintenance
and reliever (MART)
● Alternative
● Medium dose ICS-LABA with as
needed SABA however may lead to
poor adherence to may cause
exacerbations
Other Step 4 Controller
options
○ Asthma persistently uncontrolled despite
medium to high dose ICS-LABA
○ Combination triple therapy
■ Beclomethasone-Formoterol-
gylcopyrronium
■ Fluticasone-furoate-vilanterol-
umeclidinium
■ Mometasone-indacterol-gylcopyrronium
STEP 5
 Step 5
● Patients of any age despite correct
inhaler technique and good adherence
with step 4 and all other controller
options considered
● Refer to a specialist
 Step 5
● Trial of 3-6 months on high ICS-LABA
● Add LAMA/combination triple therapy
● Add Azithromycin 500mg/tab 3x/week
● Add Biologic Therapy
○ Omalizumab (anti-IgE)
■ Moderate- severe uncontrolled
ashtma
 Step 5
● Difficulty confirming diagnosis of asthma
● Suspected occupational asthma
● Persistent of severely uncontrolled asthma or
frequent exacerbations
● Significant evidence, risk treatment side-
effects
● Sub-types of asthma
○ Aspirin exacerbated respiratory disease
 After starting controller treatment
● Review patients symptom control
● 2-3 month
● Clinical urgency
● Check adherence and inhaler technique
frequently
● Step down treatment once good control
has been maintained for 3 months
 Adjusting treatment
● Patients should be seen regularly
● Symptom control
● Risk factors
● Occurrence of exacerbations
● Improvement beings within days of initiating
treatment, but full benefit may only be after
3-4 months
● Ideally patients should be seen 1-3 months
after starting treatment and every 3-12
months
● After an exacerbation 1 week should be done
 Step Up
• Day to Day adjustment
• On ICS-LABA; patient adjusts
number of as-needed doses
from day to day according to
symptoms
• Reduces the risk of developing
severe exacerbation requiring
OCS within the next 3-4 weeks
 Step up
• Short-term Step up (1-2
weeks)
• Short term increase in
maintenance ICS dose
• Viral infections or seasonal
allergen exposure
 Step Up
• Sustained Step up (for at least 2-3
months)
• Uncontrolled asthma on low dose
ICS-LABA despite good adherence
and correct technique
• Increase maintenance dose to
medium
• Address modifiable risk factors
Step Down
• Controlled asthma symptoms and lung
function stable for 3 months
• Choose an appropriate time
• No respiratory infection
• Not pregnant
• Patient not travelling
• Stepping down ICS doses by 25-50% at 3
months interval
 Step 5
Current Medication Options for Stepping
and dose down
High dose ICS-LABA + • Continue high dose
OCS ICS-LABA and reduce
OCS dose
• Replace OCS with
high dose ICS
High Dose ICS-LABA + Refer for expert advice
other add-on agents
Step 4
Current Medication and Options for Stepping
dose down
Moderate to High dose • Continue ICS-LABA and
ICS-LABA maintenance with 50% reduction
treatment
Medium dose ICS- Reduce maintenance ICS-
Formoterol as maintenance Formoterol to low dose
and reliver continue as needed ICS-
Formoterol reliever
High dose ICS plus second Reduce ICS dose by 50%
controller and continue second
Step 3
Current Medication and Options for Stepping down
dose
Low dose ICS-LABA • Reduce ICS-LABA to once
maintenance daily
Low dose ICS-Formoterol as Reduce maintenance ICS-
maintenance and reliver Formoterol once daily
continue as needed ICS-
Formoterol reliever

Medium to High dose ICS Reduce ICS dose by 50%

 Step 2
Current Medication and Options for Stepping down
dose
Low dose ICS-LABA • Once daily dosing
maintenance • Switch to as needed low
dose ICS-Formoterol
• Switch to taking ICS when
SABA is taken

Low dose ICS • Switch to as needed low

dose ICS-formoterol
 Uncontrolled/Difficult to treat
● Uncontrolled Asthma
○ Poor symptom control –frequent symptoms or
reliever use, activity limited by asthma, night waking
due to asthma
○ frequent exacerbations (>2/year) requiring OCS or
serious exacerbation (>1/year) requiring
hospitalization
● Difficult to treat
○ Uncontrolled despite on medium to high dose ICS
with second controller (usually a LABA) with
maintenance OCS required high dose treatment to
maintain good symptoms control and reduce the risk
of exacerbation
 Uncontrolled/Difficult to treat
● Uncontrolled Asthma
○ Poor symptom control –frequent symptoms or
reliever use, activity limited by asthma, night waking
due to asthma
○ frequent exacerbations (>2/year) requiring OCS or
serious exacerbation (>1/year) requiring
hospitalization
● Difficult to treat
○ Uncontrolled despite on medium to high dose ICS
with second controller (usually a LABA) with
maintenance OCS required high dose treatment to
maintain good symptoms control and reduce the risk
of exacerbation
 Referral to specialist
● Difficulty confirming diagnosis of asthma
● Frequent urgent healthcare utilization
● Frequent or maintenance OCS
● Occupational asthma is suspected
● Food allergy or anaphylaxis
● Infective or cardiac cause
● Evidence of Bronchiectasis
● Multimorbidity
 Investigate
● CBC
● CRP
● IgA, IgM, IgE, fungal precipitins
● Chest xray
● High resolution chest CT
● Bone scan
● Blood eosinophils >300uL
 Assess
● Inflammatory Phenotype
○ Type 2
● Poor symptom control on high dose ICS-LABA
○ (+) eosinophilic biomarkers
○ On OCS
● Add Biologic Type 2 Targeted treatment
 Add on biologic therapy
● Anti-immunoglobulin –
Omalizumab
● Anti-interleukin 5/5R –
Intravenous Mepolizumab
● Anti-interleukin – 4R alpha
Subcutaneous Dupilumab for
adults on OCS
● Anti-thymic Stromal
Lymphopoietin
 Review response after 3-4 months
● Symptom control
○ Symptom frequency
○ SABA reliever use
○ Night waking due to asthma
○ Activity Limitation
● Exacerbations since previous visit
● Medication side effects
● Inhaler technique and adherence
● Lung Function
● Patient satisfaction and concerns
 Review
● Type 2 comorbidities
○ Nasal polyposis
○ Atopic dermatitis
● Medications
○ Treatment intensity
○ Dose of OCS
○ Side effects
○ Affordability
 Non-Pharmacologic Strategies
● Cessation of smoking
● Encourage physical activity
● Avoid of occupational exposures
● Avoid medications that may precipitate exacerbations
● Healthy diet
● Avoidance of indoor allergens
● Weight reduction
● Breathing exercises
● Avoid of air pollution
● Avoid outdoor allergens
● Dealing with emotional stress
Thank You!