1. G IN A
lobal
itiative for
sthma

2. 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

3. 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

4. Mechanisms Underlying the Definition of Asthma
Risk Factors
(for development of asthma)
INFLAMMATION
Airway
Hyperresponsiveness
Airflow Obstruction
Symptoms
Risk Factors
(for exacerbations)

5. 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

6. 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

7. 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

8. Factors that Exacerbate Asthma
Allergens
Air Pollutants
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs

9. Risk Factors that Lead to Asthma Development
Host Factors
Genetic predisposition
Atopy
Airway hyper-
responsiveness
Gender
Race/Ethnicity
Environmental Factors
Indoor allergens
Outdoor allergens
Occupational sensitizers
Tobacco smoke
Air Pollution
Respiratory Infections
Parasitic infections
Socioeconomic factors
Family size
Diet and drugs
Obesity

10. 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

11. Asthma Diagnosis History and patterns of symptoms Physical examination
Measurements of lung function
Measurements of allergic status to identify risk factors

12. Clinical Features Before Treatment
Classification of Severity
CLASSIFY SEVERITY
Clinical Features Before Treatment
Nocturnal
Symptoms
Symptoms
FEV1 or PEF
Continuous
Limited physical activity
STEP 4
Severe Persistent
 60% predicted
Variability > 30%
Frequent
% predicted
Variability > 30%
STEP 3
Moderate Persistent
Daily
Attacks affect activity
> 1 time week
STEP 2
Mild Persistent
> 2 times a month
 80% predicted
Variability %
> 1 time a week but < 1 time a day
< 1 time a week
Asymptomatic and normal PEF between attacks
STEP 1
Intermittent
 80% predicted
Variability < 20%
 2 times a month
The presence of one feature of severity is sufficient to place patient in that category.

13. 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

14. 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

15. Goals of Long-term Management
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

16. Control of Asthma Minimal (ideally no) chronic symptoms
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

17. . 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

18. 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

19. 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

20. Provide information about asthma
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

21. Medication Usage Patient/Physician
Six-part Asthma Management Program Factors Associated with Non-Compliance in Asthma Care
Medication Usage
Difficulties associated with inhalers
Complicated regimens
Fears about, or actual side effects
Cost
Patient/Physician
Misunderstanding/lack of information
Underestimation of severity
Attitudes toward ill health
Cultural factors
Poor communication

22. 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

23. 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

24. A Simple Index of PEF Variation

25. 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

26. Reduce exposure to indoor allergens Avoid tobacco smoke
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

27. Part 4: Establish Medication Plans for Long-Term Asthma Management
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

28. Stepwise Approach to Asthma Therapy
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.

29. Pharmacologic Therapy
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

30. Reliever Medications:
Part 4: Long-term Asthma Management Pharmacologic Therapy
Reliever Medications:
Rapid-acting inhaled β2-agonists
Systemic glucocorticosteroids
Anticholinergics
Methylxanthines
Short-acting oral β2-agonists

31. Estimated Comparative Daily Dosages for Inhaled Glucocorticosteroids
Drug
Low Daily Dose (g)
Adult Child
Medium Daily Dose (g)
Adult Child
High Daily Dose (g)
Beclomethasone-CFC
> > 500
Beclomethasone-HFA
> > 400
Budesonide-DPI
> > 600
Budesonide-Neb
>1000
Flunisolde
> > 1250
Fluticasone
Mometasone furoate
> 800
Triamcinolone acetonide
> > 1200

32. Outcome: Best Possible Results Outcome: Asthma Control
Part 4: Long-term Asthma Management
Stepwise Approach to Asthma Therapy - Adults
Outcome: Best Possible Results
Outcome: Asthma Control
Controller:
Daily inhaled corticosteroid plus
Daily long –acting inhaled β2-agonist
plus (if needed)
When asthma is controlled, reduce therapy
Monitor
Controller:
Daily inhaled corticosteroid plus
Daily long-acting inhaled β2-agonist
Controller:
Daily inhaled
corticosteroid
Controller:
None
-Theophylline-SR
-Leukotriene
-Long-acting inhaled
β2- agonist
-Oral corticosteroid
Reliever:
Rapid-acting inhaled β2-agonist prn
STEP 1:
Intermittent
STEP 2:
Mild Persistent
STEP 3:
Moderate Persistent
STEP 4:
Severe Persistent
STEP Down
Alternative controller and reliever medications may be considered (see text).

33. Recommended Asthma Medications Step 1: Adults
Severity
Daily Controller Medications
Other Options (in order of cost)
Step 1:
Intermittent
None
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.

34. Recommended Asthma Medications Step 2: Adults
Severity
Daily Controller Medications
Other Options (in order of cost)
Step 2:
Mild Persistent
Low-dose inhaled glucocorticosteroid
Sustained-release theophylline, or
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.

35. Recommended Asthma Medications Step 3: Adults
Severity
Daily Controller Medications
Other Options (in order of cost)
Step 3:
Moderate persistent
Low- to medium-dose inhaled glucocortico-steroid plus long-acting inhaled β2- agonist
Medium-dose inhaled glucocorticosteroid plus sustained- release theophylline, or
Medium-dose inhaled glucocorticosteroid 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.

36. Recommended Asthma Medications Step 4: Adults
Severity
Daily Controller Medications
Other Options
Step 4
Severe persistent
High-dose inhaled glucocorticosteroid
plus long-acting inhaled β2- agonist
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.

37. 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.

38. 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

39. 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

40. 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

41. Treatment of exacerbations depends on: The patient
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

42. Primary therapies for exacerbations:
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

43. Severe exacerbations are life-threatening medical emergencies
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

44. Emergency Department Management Acute Asthma
Initial Assessment
History, Physical Examination, PEF or FEV1
Initial Therapy
Bronchodilators; O2 if needed
Incomplete/Poor Response
Add Systemic Glucocorticosteroids
Good Response
Discharge
Poor Response
Admit to Hospital
Good Response
Observe for at least 1 hour
If Stable, Discharge to Home
Respiratory Failure
Admit to ICU

45. Continual monitoring is essential to assure that
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)

46. 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

47. 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

48. 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

50. Outcome: Best Possible Results Outcome: Asthma Control
Part 4: Long-term Asthma Management
Stepwise Approach to Asthma Therapy - Adults
Outcome: Best Possible Results
Outcome: Asthma Control
Controller:
Daily inhaled corticosteroid
Daily long –acting inhaled β2-agonist
plus(if needed)
When asthma is controlled, reduce therapy
Monitor
Controller:
Daily inhaled corticosteroid
Daily long-acting inhaled β2-agonist
Controller:
Daily inhaled
corticosteroid
Controller:
None
-Theophylline-SR
-Leukotriene
-Long-acting inhaled
β2- agonist
-Oral corticosteroid
Reliever:
Rapid-acting inhaled β2-agonist prn
STEP 1:
Intermittent
STEP 2:
Mild Persistent
STEP 3:
Moderate Persistent
STEP 4:
Severe Persistent
STEP Down
Alternative controller and reliever medications may be considered (see text).

51. Step 1: Intermittent Asthma
Stepwise Approach to Asthma Therapy: Adults
Step 1: Intermittent Asthma
Reliever
Medications
Daily Controller Medications
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
None required
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

52. Daily Controller Medications
Stepwise Approach to Asthma Therapy: Adults Step 2: Mild Persistent Asthma
Daily Controller Medications
Reliever Medications
Low-dose inhaled
glucocorticosteroid
Other options (order by cost):
sustained-release theophylline, or
Cromone, or
leukotriene modifier
Rapid-acting inhaled 2-agonist
for symptoms (but < 3-4 times/day)
Other options:
inhaled anticholinergic, or
short-acting oral 2-agonist, or
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

53. Step 3: Moderate Persistent Asthma
Stepwise Approach to Asthma Therapy: Adults
Step 3: Moderate Persistent Asthma
Daily Controller
Medications
Reliever Medications
Low- to medium-dose inhaled glucocortico-
steroid, plus long-acting inhaled 2-agonist
Other options (order by cost):
Medium-dose inhaled glucocorticosteroid plus sustained-release theophylline, or
Medium-dose inhaled glucocorticosteroid plus long-acting inhaled β2- agonist, or
High-dose inhaled glucocorticosteroid, or
Medium-dose inhaled glucocorticosteroid plus leukotriene modifier
Rapid-acting inhaled
2-agonist for symptoms
(but < times/day)
Other options:
inhaled anticholinergic or
short-acting oral
2-agonist or
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.

54. Step 4: Severe Persistent Asthma
Stepwise Approach to Asthma Therapy: Adults
Step 4: Severe Persistent Asthma
Daily Controller
Medications
Reliever Medications
High-dose inhaled glucocorticosteroid,
plus long-acting inhaled β2agonist
plus one or more of the following, if
needed (order by cost):
sustained-release theophylline, or
leukotriene modifier or
oral glucocorticosteroid
Rapid-acting inhaled
2-agonist for symptoms
(but < 3-4 times/day)
Other options:
inhaled anticholinergic or
short-acting oral
2-agonist or
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.