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POCKET GUIDE FORASTHMA MANAGEMENTAND PREVENTION
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(for Adults and Children Older than 5 Years)
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A Pocket Guide for Physicians and NursesRevised 2014
BASED ON THE GLOBAL STRATEGY FOR ASTHMAMANAGEMENT AND PREVENTION
Global Initiative for Asthma
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GLOBAL INITIATIVEFOR ASTHMA
GINA Board of Directors
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POCKET GUIDE FOR PHYSICIANSAND NURSES 2014
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Chair: J Mark FitzGerald, MD
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GINA Science Committee
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Chair: Helen Reddel, MBBS PhDGINA Dissemination and
Implementation Committee
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Chair: Louis-Philippe Boulet, MD
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GINA Assembly
The GINA Assembly includes members from 45 countries, listed on
theGINA website www.ginasthma.org.GINA Program
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Scientific Director: Suzanne Hurd, PhD
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Names of members of the GINA Committees are listed on page
28.
1
TABLE OF CONTENTS3
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Preface
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Making the diagnosis of asthmaCriteria for making the diagnosis
of asthmaDiagnosing asthma in special populationsAssessing a
patient with asthmaHow to assess asthma controlHow to investigate
uncontrolled asthmaManagement of asthma general principlesTreating
to control symptoms and minimize riskInitial controller
treatmentStepwise approach for adjusting treatmentReviewing
response and adjusting treatmentInhaler skills and
adherenceTreating modifiable risk factorsNon-pharmacological
strategies and interventionsTreatment in special populations or
contextsAsthma flare-ups (exacerbations)Written asthma action
plansManaging exacerbations in primary or acute careFollow-up after
an exacerbationGlossary of asthma medication classes
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What is known about asthma?
Acknowledgements
2828
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TABLE OF FIGURES
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GINA publications
56789101111131617181919202122232526
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Box 1. Diagnostic flow-chart for asthma in clinical
practice........................... 5Box 2. Features used in making
the diagnosis of asthma............................. 6Box 3. How to
assess a patient with
asthma................................................. 8Box 4.
Assessment of symptom control and future risk
................................ 9Box 5. How to investigate
uncontrolled asthma in primary care.................. 10Box 6. The
control-based asthma management cycle
................................ 12Box 7. Stepwise approach to
asthma treatment ......................................... 14Box 8.
Low, medium and high daily doses of inhaled corticosteroids (mcg)
14Box 9. Self-management with a written action plan
.................................... 22Box 10. Management of asthma
exacerbations in primary care ................. 24
Abbreviations used in this Pocket Guide are found on page
27.2
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PREFACE
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Asthma affects an estimated 300 million individuals worldwide.
It is a seriousglobal health problem affecting all age groups, with
increasing prevalence inmany developing countries, rising treatment
costs, and a rising burden forpatients and the community. Asthma
still imposes an unacceptable burden onhealth care systems, and on
society through loss of productivity in theworkplace and,
especially for pediatric asthma, disruption to the family.
OR
Health care providers managing asthma face different issues
around theworld, depending on the local context, the health system,
and access toresources.
NOT
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The Global Initiative for Asthma (GINA) was established to
increaseawareness about asthma among health professionals, public
healthauthorities and the community, and to improve prevention and
managementthrough a coordinated worldwide effort. GINA prepares
scientific reports onasthma, encourages dissemination and
implementation of therecommendations, and promotes international
collaboration on asthmaresearch.
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The Global Strategy for Asthma Management and Prevention 2014
hasbeen extensively revised to provide a comprehensive and
integratedapproach to asthma management that can be adapted for
local conditionsand for individual patients. It focuses not only on
the existing strong evidencebase, but also on clarity of language
and on providing tools for feasibleimplementation in clinical
practice.
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This Pocket Guide is a brief summary of the GINA 2014 report for
primaryhealth care providers. It does NOT contain all of the
information required formanaging asthma, for example, about safety
of treatments, and should beused in conjunction with the full GINA
report.
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The GINA 2014 report and other GINA publications (listed on page
28) can beobtained from www.ginasthma.org.
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Implementation of the treatment recommendations in thisPocket
Guide is subject to local resources and regulations.
3
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WHAT IS KNOWN ABOUT ASTHMA?
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Asthma is a common and potentially serious chronic disease
thatimposes a substantial burden on patients, their families and
the community. Itcauses respiratory symptoms, limitation of
activity, and flare-ups (attacks) thatsometimes require urgent
health care and may be fatal.
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Fortunatelyasthma can be effectively treated, and most patients
canachieve good control of their asthma. When asthma is under good
control,patients can:
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Avoid troublesome symptoms during day and nightNeed little or no
reliever medicationHave productive, physically active livesHave
normal or near normal lung functionAvoid serious asthma flare-ups
(exacerbations, or attacks)
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What is asthma? Asthma causes symptoms such as wheezing,
shortness ofbreath, chest tightness and cough that vary over time
in their occurrence,frequency and intensity.
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These symptoms are associated with variable expiratory airflow,
i.e. difficultybreathing air out of the lungs due to
bronchoconstriction (airway narrowing),airway wall thickening, and
increased mucus. Some variation in airflow canalso occur in people
without asthma, but it is greater in asthma.
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Factors that may trigger or worsen asthma symptoms include
viralinfections, domestic or occupational allergens (e.g. house
dust mite, pollens,cockroach), tobacco smoke, exercise and stress.
These responses are morelikely when asthma is uncontrolled. Some
drugs can induce or trigger asthma,e.g. beta-blockers, and (in some
patients), aspirin or other NSAIDs.
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Asthma flare-ups (also called exacerbations or attacks) may
occur, even inpeople taking asthma treatment. When asthma is
uncontrolled, or in somehigh-risk patients, these episodes are more
frequent and more severe, andmay be fatal.
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A stepwise approach to treatment takes into account the
effectiveness ofavailable medications, their safety, and their cost
to the payer or patient.
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Regular controller treatment, particularly with inhaled
corticosteroid (ICS)containing medications, markedly reduces the
frequency and severity ofasthma symptoms and the risk of having a
flare-up.
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Asthma is a common condition, affecting all levels of society.
Olympicathletes, famous leaders and celebrities, and ordinary
people live successfuland active lives with asthma.
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MAKING THE DIAGNOSIS OF ASTHMA
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Asthma is a disease with many variations (heterogeneous),
usuallycharacterized by chronic airway inflammation. Asthma has two
key definingfeatures:
a history of respiratory symptoms such as wheeze, shortness of
breath,chest tightness and cough that vary over time and in
intensity, AND
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variable expiratory airflow limitation.
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A flow-chart for making the diagnosis in clinical practice is
shown in Box 1,with the specific criteria for diagnosing asthma in
Box 2.
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Box 1. Diagnostic flow-chart for asthma in clinical practice
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The diagnosis of asthma should be confirmed and, for future
reference, theevidence documented in the patients notes. Depending
on clinical urgencyand access to resources, this should preferably
be done before startingcontroller treatment. Confirming the
diagnosis of asthma is more difficult aftertreatment has been
started (see p7).5
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CRITERIA FOR MAKING THE DIAGNOSIS OF ASTHMABox 2. Features used
in making the diagnosis of asthma
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1. A history of variable respiratory symptoms
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Typical symptoms are wheeze, shortness of breath, chest
tightness, coughPeople with asthma generally have more than one of
these symptomsThe symptoms occur variably over time and vary in
intensityThe symptoms often occur or are worse at night or on
wakingSymptoms are often triggered by exercise, laughter, allergens
or cold airSymptoms often occur with or worsen with viral
infections
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2. Evidence of variable expiratory airflow limitation
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At least once during the diagnostic process when FEV1 is
low,document that the FEV1/FVC ratio is reduced. The FEV1/FVC ratio
isnormally more than 0.750.80 in adults, and more than 0.90 in
children.
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Document that variation in lung function is greater than in
healthypeople. For example:o FEV1 increases by more than 12% and
200mL (in children, >12%of the predicted value) after inhaling a
bronchodilator. This iscalled bronchodilator reversibility.o
Average daily diurnal PEF variability* is >10% (in children,
>13%)o FEV1 increases by more than 12% and 200mL from baseline
(inchildren, by >12% of the predicted value) after 4 weeks of
antiinflammatory treatment (outside respiratory infections)The
greater the variation, or the more times excess variation is
seen,the more confident you can be of the diagnosis
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Testing may need to be repeated during symptoms, in the
earlymorning, or after withholding bronchodilator medications.
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Bronchodilator reversibility may be absent during severe
exacerbationsor viral infections. If bronchodilator reversibility
is not present when it isfirst tested, the next step depends on the
clinical urgency andavailability of other tests.
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For other tests to assist in diagnosis, including bronchial
challengetests, see Chapter 1 of the GINA 2014 report.
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*Calculated from twice daily readings (best of 3 each time), as
([the days highest PEFminus the days lowest PEF]) divided by the
mean of the days highest and lowest PEF,and averaged over 1-2
weeks. If using PEF at home or in the office, use the same PEFmeter
each time.
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Physical examination in people with asthma is often normal, but
the mostfrequent finding is wheezing on auscultation, especially on
forced expiration.
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DIAGNOSING ASTHMA IN SPECIAL POPULATIONSPatients with cough as
the only respiratory symptom
OR
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This may be due to chronic upper airway cough syndrome
(post-nasal drip),chronic sinusitis, gastroesophageal reflux
(GERD), vocal cord dysfunction, oreosinophilic bronchitis, or cough
variant asthma. Cough variant asthma ischaracterized by cough and
airway hyperresponsiveness, and documentingvariability in lung
function is essential to make this diagnosis. However, lack
ofvariability at the time of testing does not exclude asthma. For
other diagnostictests, see Box 2, and Chapter 1 of the GINA 2014
report, or refer the patientfor specialist opinion.Occupational
asthma and work-aggravated asthma
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Every patient with adult-onset asthma should be asked about
occupationalexposures, and whether their asthma is better when they
are away from work.It is important to confirm the diagnosis
objectively (which often needsspecialist referral) and to eliminate
exposure as soon as possible.Pregnant women
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Ask all pregnant women and those planning pregnancy about
asthma, andadvise them about the importance of asthma treatment for
the health of bothmother and baby.
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The elderly
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Asthma may be under-diagnosed in the elderly, due to poor
perception, anassumption that dyspnea is normal in old age, lack of
fitness, or reducedactivity. Asthma may also be over-diagnosed in
the elderly through confusionwith shortness of breath due to left
ventricular failure or ischemic heartdisease. If there is a history
of smoking or biomass fuel exposure, COPD orasthma-COPD overlap
syndrome (ACOS) should be considered (see Chapter5 of the GINA 2014
report).Smokers and ex-smokers
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Asthma and COPD may co-exist or overlap (asthma-COPD
overlapsyndrome, ACOS), particularly in smokers and the elderly.
The history andpattern of symptoms and past records can help to
distinguish asthma withfixed airflow limitation from COPD.
Uncertainty in diagnosis should promptearly referral, as ACOS has
worse outcomes than asthma or COPD alone.
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Confirming an asthma diagnosis in patients taking controller
treatment:
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For many patients (2535%) with a diagnosis of asthma in primary
care, thediagnosis cannot be confirmed. If the basis of the
diagnosis has not alreadybeen documented, confirmation with
objective testing should be sought.If standard criteria for asthma
(Box 2) are not met, consider otherinvestigations. For example, if
lung function is normal, repeat reversibility7
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testing after withholding medications for 12 hours. If the
patient has frequentsymptoms, consider a trial of step-up in
controller treatment and repeat lungfunction testing after 3
months. If the patient has few symptoms, considerstepping down
controller treatment, but ensure the patient has a writtenasthma
action plan, monitor them carefully, and repeat lung function
testing.
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ASSESSING A PATIENT WITH ASTHMA
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Box 3. How to assess a patient with asthma
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Take every opportunity to assess patients with a diagnosis of
asthma,particularly when they are symptomatic or after a recent
exacerbation, butalso when they ask for a prescription refill. In
addition, schedule a routinereview at least once a year.
1. Asthma control assess both symptom control and risk
factors
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Assess symptom control over the last 4 weeks (Box 4, p9)Identify
any other risk factors for poor outcomes (Box 4)Measure lung
function before starting treatment, 36 months later, andthen
periodically, e.g. yearly
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2. Treatment issues
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Record the patients treatment (Box 7, p14), and ask about
side-effectsWatch the patient using their inhaler, to check their
technique (p18)Have an open empathic discussion about adherence
(p18)Check that the patient has a written asthma action plan
(p22)Ask the patient about their attitudes and goals for their
asthma
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3. Are there any comorbidities?
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These include rhinitis, rhinosinusitis, gastroesophageal reflux
(GERD),obesity, obstructive sleep apnea, depression and
anxiety.
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Comorbidities should be identified as they may contribute to
respiratorysymptoms and poor quality of life. Their treatment may
complicateasthma management.
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HOW TO ASSESS ASTHMA CONTROL
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Asthma control means the extent to which the effects of asthma
can be seenin the patient, or have been reduced or removed by
treatment. Asthma controlhas two domains: symptom control
(previously called current clinical control)and risk factors for
future poor outcomes.
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Poor symptom control is a burden to patients and a risk factor
for flare-ups.Risk factors are factors that increase the patients
future risk of havingexacerbations (flare-ups), loss of lung
function, or medication side-effects.
A. Level of asthma symptom control
YesYesYesYes
NoNoNoNo
Uncontrolled
12of these
34of these
Noneof these
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Daytime symptoms more than twice/week?Any night waking due to
asthma?Reliever needed* more than twice/week?Any activity
limitation due to asthma?
Partlycontrolled
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Wellcontrolled
In the past 4 weeks, has the patient had:
OR
Box 4. Assessment of symptom control and future risk
B. Risk factors for poor asthma outcomes
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Assess risk factors at diagnosis and periodically, particularly
for patients experiencingexacerbations.Measure FEV1 at start of
treatment, after 36 months of controller treatment to
recordpersonal best lung function, then periodically for ongoing
risk assessment.
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Potentially modifiable independent risk factors for
exacerbations include:
Having one or moreof these risk factorsincreases the risk
ofexacerbations evenif symptoms are wellcontrolled.
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Uncontrolled asthma symptoms (as above)ICS not prescribed; poor
ICS adherence; incorrect inhaler techniqueExcessive SABA use
(>1x200-dose canister/month)Low FEV1, especially if 5001000 N
>1000100200>200400>400O>400Beclometasone dipropionate
(HFA)100200>20040050-100>100-200>200TABudesonide
(DPI)200400>400800>800>200400>400LT100200Budesonide
(nebules)250500>5001000>1000E80RCiclesonide
(HFA)80160>160320>320>80-160>160Fluticasone propionate(
DPI)100250>250500>500100200O>200400>400R
>200500Fluticasone propionate
(HFA)100250>250500>500100200>500RE220440>440110PR
>1200Triamcinolone
acetonide4001000>10002000>2000400800>8001200ODCFC:
chlorofluorocarbon propellant; DPI: dry powder inhaler; HFA:
hydrofluoroalkane propellant.UC*Included for comparison with older
literature.E
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STEPWISE APPROACH FOR ADJUSTING TREATMENT
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Once asthma treatment has been started, ongoing decisions are
based on acycle to assess, adjust treatment and review response.
The preferredtreatments at each step are summarized below and in
Box 7 (p14); for details,see full GINA 2014 report. See Box 8 (p14)
for ICS dose categories.
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STEP 1: As-needed SABA with no controller (this is indicated
only ifsymptoms are rare, there is no night waking due to asthma,
noexacerbations in the last year, and normal FEV1).Other options:
regular low dose ICS for patients with exacerbation risks.
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STEP 2: Regular low dose ICS plus as-needed SABAOther options:
LTRA are less effective than ICS; ICS/LABA leads to
fasterimprovement in symptoms and FEV1 than ICS alone but are
moreexpensive and the exacerbation rate is similar. For purely
seasonal allergicasthma, start ICS immediately and cease 4 weeks
after end of exposure.
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STEP 3: Low dose ICS/LABA either as maintenance treatment plus
asneeded SABA, or as ICS/formoterol maintenance and reliever
therapy
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or BUD/formoterol maintenance and reliever strategy is more
effective thanmaintenance ICS/LABA with as-needed SABA.Other
options: Medium dose ICSChildren (611 years): Medium dose ICS.
Other options: low doseICS/LABA
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STEP 4: Low dose ICS/formoterol maintenance and reliever
therapy, ormedium dose ICS/LABA as maintenance plus as-needed
SABAOther options: high dose ICS/LABA, but more side-effects and
little extrabenefit; extra controller, e.g. LTRA or slow-release
theophylline (adults)Children (611 years): Refer for expert
assessment and advice.
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STEP 5: Refer for expert investigation and add-on
treatmentAdd-on treatments include anti-IgE (omalizumab) for severe
allergic asthma.Sputum-guided treatment, if available, improves
outcomes.Other options: Some patients may benefit from low dose OCS
but long-termsystemic side-effects occur.
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REVIEWING RESPONSE AND ADJUSTING TREATMENTHow often should
patients with asthma be reviewed?
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Patients should preferably be seen 13 months after starting
treatment andevery 312 months after that, except in pregnancy when
they should bereviewed every 46 weeks. After an exacerbation, a
review visit within 1 weekshould be scheduled. The frequency of
review depends on the patients initiallevel of control, their
response to previous treatment, and their ability andwillingness to
engage in self-management with an action plan.
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Stepping up asthma treatment
Asthma is a variable condition, and periodic adjustment of
controller treatmentby the clinician and/or patient may be
needed.
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Sustained step-up (for at least 23 months): if symptoms
and/orexacerbations persist despite 23 months of controller
treatment, assessthe following common issues before considering a
step-upo Incorrect inhaler techniqueo Poor adherenceo Modifiable
risk factors, e.g. smokingo Are symptoms due to comorbid
conditions, e.g. allergic rhinitisShort-term step-up (for 12 weeks)
by clinician or by patient with writtenasthma action plan (p22),
e.g. during viral infection or allergen exposureDay-to-day
adjustment by patient for patients prescribed low
dosebeclometasone/formoterol or budesonide/formoterol as
maintenance andreliever therapy.
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Stepping down treatment when asthma is well-controlled
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Consider stepping down treatment once good asthma control has
beenachieved and maintained for 3 months, to find the lowest
treatment thatcontrols both symptoms and exacerbations, and
minimizes side-effects.
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Choose an appropriate time for step-down (no respiratory
infection,patient not travelling, not pregnant)Document baseline
status (symptom control and lung function), provide awritten asthma
action plan, monitor closely, and book a follow-up visitStep down
through available formulations to reduce the ICS dose by2550% at 23
month intervals (see full GINA report for details)Do not completely
withdraw ICS (in adults or adolescents) unless it isneeded
temporarily to confirm the diagnosis of asthma
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INHALER SKILLS AND ADHERENCEProvide skills training for
effective use of inhaler devices
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Most patients (up to 80%) cannot use their inhaler correctly.
This contributesto poor symptom control and exacerbations. To
ensure effective inhaler use:
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Choose the most appropriate device for the patient before
prescribing:consider medication, physical problems e.g. arthritis,
patient skills, andcost; for ICS by pressurized metered dose
inhaler, prescribe a spacer.
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Check inhaler technique at every opportunity. Ask the patient to
showyou how they use the inhaler. Check their technique against a
devicespecific checklist.
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Correct using a physical demonstration, paying attention to
incorrectsteps. Check technique again, up to 23 times if
necessary.Confirm that you have checklists for each of the inhalers
you prescribe,and can demonstrate correct technique on them.
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Information about inhaler devices and techniques for their use
can be foundon the GINA website (www.ginasthma.org) and the ADMIT
website(www.admit-online.info).Check and improve adherence with
asthma medications
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Around 50% of adults and children do not take controller
medications asprescribed. Poor adherence contributes to poor
symptom control andexacerbations. It may be unintentional (e.g.
forgetfulness, cost,misunderstandings) and/or non-intentional (e.g.
not perceiving the need fortreatment, fear of side-effects,
cultural issues, cost).
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To identify patients with adherence problems:
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Ask an empathic question, e.g. Most patients dont take their
inhalerexactly as prescribed. In the last 4 weeks, how many days a
week haveyou been taking it? 0 days a week, or 1, or 2 days [etc]?,
or Do you findit easier to remember your inhaler in the morning or
night?Check medication usage, from prescription date, inhaler
date/dosecounter, dispensing recordsAsk about attitudes and beliefs
about asthma and medicationsOnly a few adherence interventions have
been studied closely in asthma.
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Shared decision-making for medication and dose choiceInhaler
reminders for missed dosesReduced complexity of the regimen (once-
vs twice-daily)Comprehensive asthma education with home visits by
asthma nursesClinicians reviewing feedback on their patients
dispensing records
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TREATING MODIFIABLE RISK FACTORS
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Exacerbation risk can be minimized by optimizing asthma
medications, andby identifying and treating modifiable risk
factors. Some examples of riskmodifiers with consistent high
quality evidence are:
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OR
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Guided self-management: self-monitoring of symptoms and/or PEF,
awritten asthma action plan (p22), and regular medical reviewUse of
a regimen that minimizes exacerbations: prescribe an ICScontaining
controller. For patients with 1 or more exacerbations in the
lastyear, consider a low dose ICS/formoterol maintenance and
relieverregimenAvoidance of exposure to tobacco smokeConfirmed food
allergy: appropriate food avoidance; ensure availabilityof
injectable epinephrine for anaphylaxisFor patients with severe
asthma: refer to a specialist center, ifavailable, for
consideration of add-on medications and/or
sputum-guidedtreatment.
NOT
NON-PHARMACOLOGICAL STRATEGIES AND INTERVENTIONS
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In addition to medications, other therapies and strategies may
be consideredwhere relevant, to assist in symptom control and risk
reduction. Someexamples with consistent high quality evidence
are:
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Smoking cessation advice: at every visit, strongly encourage
smokers toquit. Provide access to counselling and resources. Advise
parents andcarers to exclude smoking in rooms/cars used by children
with asthmaPhysical activity: encourage people with asthma to
engage in regularphysical activity because of its general health
benefits. Provide adviceabout management of exercise-induced
bronchoconstriction.Occupational asthma: ask all patients with
adult-onset asthma about theirwork history. Identify and remove
occupational sensitizers as soon aspossible. Refer patients for
expert advice, if available.NSAIDs including aspirin: always ask
about asthma before prescribing.Breathing techniques: may be a
useful supplement to medications
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Although allergens may contribute to asthma symptoms in
sensitized patients,allergen avoidance is not recommended as a
general strategy for asthma.These strategies are often complex and
expensive, and there are no validatedmethods for identifying those
who are likely to benefit.
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Some common triggers for asthma symptoms (e.g. exercise,
laughter) shouldnot be avoided, and others (e.g. viral respiratory
infections, stress) aredifficult to avoid and should be managed
when they occur.
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TREATMENT IN SPECIAL POPULATIONS OR CONTEXTS
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Pregnancy: asthma control often changes during pregnancy. For
baby andmother, the advantages of actively treating asthma markedly
outweigh anypotential risks of usual controller and reliever
medications. Down-titration hasa low priority in pregnancy.
Exacerbations should be treated aggressively.
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Rhinitis and sinusitis often coexist with asthma. Chronic
rhinosinusitis isassociated with more severe asthma. For some
patients, treatment withintranasal corticosteroids improves asthma
control.
ALTER
OR
Obesity: to avoid over- or under-treatment, it is important to
document thediagnosis of asthma in the obese. Asthma is more
difficult to control inobesity. Weight reduction should be included
in the treatment plan for obesepatients with asthma; even 510%
weight loss can improve asthma control.
NOT
The elderly: comorbidities and their treatment should be
considered and maycomplicate asthma management. Factors such as
arthritis, eyesight,inspiratory flow, and complexity of treatment
regimens should be consideredwhen choosing medications and inhaler
devices.
-DO
Gastroesophageal reflux (GERD) is commonly seen in
asthma.Symptomatic reflux should be treated for its general health
benefits, but thereis no benefit from treating asymptomatic reflux
in asthma.
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Anxiety and depression: these are commonly seen in people with
asthma,and are associated with worse symptoms and quality of life.
Patients shouldbe assisted to distinguish between symptoms of
anxiety and of asthma.
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Aspirin-exacerbated respiratory disease (AERD): a history of
exacerbationfollowing ingestion of aspirin or other NSAIDs is
highly suggestive. Patientsoften have severe asthma and nasal
polyposis. Confirmation of the diagnosisof AERD requires challenge
in a specialized center with cardiopulmonaryresuscitation
facilities, but avoidance of NSAIDs may be recommended on thebasis
of a clear history. ICS are the mainstay of treatment, but OCS may
berequired. Desensitization under specialist care is sometimes
effective.
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Food allergy and anaphylaxis: food allergy is rarely a trigger
for asthmasymptoms. It must be assessed with specialist testing.
Confirmed food allergyis a risk factor for asthma-related death.
Good asthma control is essential;patients should also have an
anaphylaxis plan and be trained in appropriateavoidance strategies
and use of injectable epinephrine.
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Surgery: whenever possible, good asthma control should be
achieved preoperatively. Ensure that controller therapy is
maintained throughout the perioperative period. Patients on
long-term high dose ICS, or having more than 2weeks OCS in the past
6 months, should receive intra-operativehydrocortisone to reduce
the risk of adrenal crisis.
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ASTHMA FLARE-UPS (EXACERBATIONS)
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A flare-up or exacerbation is an acute or sub-acute worsening in
symptomsand lung function from the patients usual status;
occasionally it may be theinitial presentation of asthma.
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For discussion with patients, the word flare-up is preferred.
Episodes,attacks and acute severe asthma are often used, but they
have variablemeanings, particularly for patients.
OR
The management of worsening asthma and exacerbations should
beconsidered as a continuum, from self-management by the patient
with awritten asthma action plan, through to management of more
severesymptoms in primary care, the emergency department and in
hospital.
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Identifying patients at risk of asthma-related death
These patients should be identified, and flagged for more
frequent review.
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A history of near-fatal asthma requiring intubation and
ventilationHospitalization or emergency care for asthma in last 12
monthsNot currently using ICS, or poor adherence with ICSCurrently
using or recently stopped using OCS (this indicates the severityof
recent events)Over-use of SABAs, especially more than 1
canister/monthLack of a written asthma action planHistory of
psychiatric disease or psychosocial problemsConfirmed food allergy
in a patient with asthma
21
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WRITTEN ASTHMA ACTION PLANS
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All patients should be provided with a written asthma action
plan appropriatefor their level of asthma control and health
literacy, so they know how torecognize and respond to worsening
asthma.
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Box 9. Self-management with a written action plan
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The written asthma action plan should include:
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The patients usual asthma medicationsWhen and how to increase
medications, and start OCSHow to access medical care if symptoms
fail to respond
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The action plan can be based on symptoms and/or (in adults) PEF.
Patientswho deteriorate quickly should be advised to go to an acute
care facility orsee their doctor immediately.
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Medication changes for written asthma action plans
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Increase frequency of inhaled reliever (SABA, or low dose
ICS/formoterol ifusing maintenance and reliever regimen); add
spacer for pMDI.
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Increase controller: Rapid increase in ICS component up to max.
2000mcgBDP equivalent. Options depend on usual controller
medication, as follows:ICS: At least double dose, consider
increasing to high dose.Maintenance ICS/formoterol: Quadruple
maintenance ICS/formoteroldose (to maximum formoterol dose of 72
mcg/day).Maintenance ICS/salmeterol: Step up at least to higher
dose formulation;consider adding separate ICS inhaler to achieve
high ICS dose.Maintenance and reliever ICS/formoterol: Continue
maintenance dose;increase as-needed ICS/formoterol (maximum
formoterol 72 mcg/day).
CO
Oral corticosteroids (preferably morning dosing):Adults -
prednisolone 1mg/kg/day up to 50mg, usually for 57 days.For
children, 12 mg/kg/day up to 40mg, usually for 35 days.Tapering not
needed if treatment has been given for less than 2 weeks.22
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MANAGING EXACERBATIONS IN PRIMARY OR ACUTE CARE
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Assess exacerbation severity while starting SABA and oxygen.
Assessdyspnea (e.g. is the patient able to speak sentences, or only
words),respiratory rate, pulse rate, oxygen saturation and lung
function (e.g. PEF).Check for anaphylaxis.
REP
Consider alternative causes of acute breathlessness (e.g. heart
failure,upper airway dysfunction, inhaled foreign body or pulmonary
embolism).
OR
Arrange immediate transfer to an acute care facility if there
are signs ofsevere exacerbation, or to intensive care if the
patient is drowsy, confused, orhas a silent chest. For these
patients, immediately give inhaled SABA, inhaledipratropium
bromide, oxygen and systemic corticosteroids.
NOT
ALTER
Start treatment with repeated doses of SABA (usually by pMDI and
spacer),early oral corticosteroids, and controlled flow oxygen if
available. Checkresponse of symptoms and saturation frequently, and
measure lung functionafter 1 hour. Titrate oxygen to maintain
saturation of 9395% in adults andadolescents (9498% in children 612
years).
-DO
For severe exacerbations, add ipratropium bromide, and consider
givingSABA by nebulizer. In acute care facilities, intravenous
magnesium sulfatemay be considered if the patient is not responding
to intensive initialtreatment.
AL
Do not routinely perform chest X-ray or blood gases, or
prescribe antibiotics,for asthma exacerbations.
RI
REVIEWING RESPONSE
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Monitor patients closely and frequently during treatment, and
titratetreatment according to response. Transfer the patient to
higher level care ifworsening or failing to respond.
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Decide about need for hospitalization based on clinical
status,symptomatic and lung function, response to treatment, recent
and past historyof exacerbations, and ability to manage at
home.
PYR
Before discharge, arrange ongoing treatment. For most patients,
prescriberegular controller therapy (or increase current dose) to
reduce the risk offurther exacerbations. Continue increased
controller doses for 24 weeks,and reduce reliever to as-needed.
Check inhaler technique and adherence.Provide an interim written
asthma action plan.
CO
Arrange early follow-up after any exacerbation, preferably
within 1 week.Consider referral for specialist advice for patients
with an asthmahospitalization, or repeated emergency department
presentations.23
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Box 10. Management of asthma exacerbations in primary care
24
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FOLLOW-UP AFTER AN EXACERBATION
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Exacerbations often represent failures in chronic asthma care,
and theyprovide opportunities to review the patients asthma
management. All patientsmust be followed up regularly by a health
care provider until symptoms andlung function return to normal.
OR
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Take the opportunity to review:The patients understanding of the
cause of the exacerbationModifiable risk factors for exacerbations,
e.g. smokingUnderstanding of purposes of medications, and inhaler
technique skillsReview and revise written asthma action plan
ALTER
Discuss medication use, as adherence with ICS and OCS may fall
to 50%within a week after discharge.
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NOT
Comprehensive post-discharge programs that include optimal
controllermanagement, inhaler technique, self-monitoring, written
asthma action planand regular review are cost-effective and are
associated with significantimprovement in asthma outcomes.
25
GLOSSARY OF ASTHMA MEDICATION CLASSES
Action and use
Adverse effects
Inhaled corticosteroids(ICS) (pMDIs or DPIs)
e.g.beclometasone,budesonide, ciclesonide,fluticasone
propionate,fluticasone furoate,mometasone, triamcinolone
The most effective anti-inflammatorymedications for persistent
asthma. ICSreduce symptoms, increase lung function,improve quality
of life, and reduce the riskof exacerbations and
asthma-relatedhospitalizations or death. ICS differ intheir potency
and bioavailability, but mostof the benefit is seen at low doses
(seeBox 8 (p14) for low, medium and highdoses of different
ICS).
Most patients using ICS donot experience side-effects.Local
side-effects includeoropharyngeal candidiasis anddysphonia. Use of
spacer withpMDI, and rinsing with waterand spitting out
afterinhalation, reduce local sideeffects. High doses increasethe
risk of systemic sideeffects.
ICS and long-acting beta2agonist bronchodilatorcombinations
(ICS/LABA)(pMDIs or DPIs) e.g.beclometasone/
formoterol,budesonide/formoterol,fluticasone furoate/vilanterol,
fluticasonepropionate/formoterol,fluticasone propionate/salmeterol,
andmometasone/formoterol.
When a medium dose of ICS alone fails toachieve good control of
asthma, theaddition of LABA to ICS improvessymptoms, lung function
and reducesexacerbations in more patients, morerapidly, than
doubling the dose of ICS.Two regimens are available:
maintenanceICS/LABA with SABA as reliever, and lowdose combination
beclometasone orbudesonide with formoterol formaintenance and
reliever treatment.
Leukotriene modifiers(tablets) e.g. montelukast,pranlukast,
zafirlukast,zileuton
Target one part of the inflammatoryFew side-effects
exceptpathway in asthma. Used as an option for elevated liver
function testscontroller therapy, particularly in children. with
zileuton and zafirlukast.Used alone: less effective than low
doseICS; added to ICS: less effective thanICS/LABA.
RODU
Medications
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For more details, see full GINA 2014 report and Appendix
(www.ginasthma.org) andProduct Information from manufacturers.
The LABA component may beassociated with tachycardia,headache or
cramps. Currentrecommendations are thatLABA and ICS are safe
forasthma when used incombination. Use of LABAwithout ICS in asthma
isassociated with increased riskof adverse outcomes.
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CONTROLLER MEDICATIONS
Very limited role in long-term treatment ofasthma. Weak
anti-inflammatory effect,less effective than low-dose ICS.
Requiremeticulous inhaler maintenance.
Anti-IgE (omalizumab)
A treatment option for patients with severe Reactions at the
site ofpersistent allergic asthma uncontrolled on injection are
common butStep 4 treatment (high dose ICS/LABA). minor. Anaphylaxis
is rare.
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Chromones (pMDIs orDPIs) e.g. sodiumcromoglycate andnedocromil
sodium
26
Side effects are uncommonbut include cough uponinhalation and
pharyngealdiscomfort.
Action and use
Adverse effects
Systemic corticosteroids(tablets,suspension orintramuscular (IM)
orintravenous (IV) injection)e.g.
prednisone,prednisolone,methylprednisolone,hydrocortisone
Short-term treatment (usually 57 days inadults) is important
early in the treatmentof severe acute exacerbations, with
maineffects seen after 46 hours. Oralcorticosteroid (OCS) therapy
is preferredand is as effective as IM or IV therapy inpreventing
relapse. Tapering is required iftreatment given for more than 2
weeks.Long-term treatment with OCS may berequired for some patients
with severeasthma.
Short-term use: some adverseeffects e.g.
hyperglycaemia,gastro-intestinal side-effects,mood
changes.Long-term use: limited by therisk of significant
systemicadverse effects e.g. cataract,glaucoma,
osteoporosis,adrenal suppression. Patientsshould be assessed
forosteoporosis risk and treatedappropriately.
OR
REP
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Medications
RELIEVER MEDICATIONSInhaled SABAs are medications of choicefor
quick relief of asthma symptoms andbronchoconstriction including in
acuteexacerbations, and for pre-treatment ofexercise-induced
bronchoconstriction.SABAs should be used only as-needed atthe
lowest dose and frequency required.
Tremor and tachycardia arecommonly reported with initialuse of
SABA, but tolerance tothese effects usually developsrapidly. Excess
use, or poorresponse indicate poorasthma control.
Short-actinganticholinergics (pMDIsor DPIs) e.g.
ipratropiumbromide,oxitropium bromide
Long-term use: ipratropium is a lessDryness of the mouth or
aeffective reliever medication than SABAs. bitter taste.Short-term
use in acute asthma: inhaledipratropium added to SABA reduces
therisk of hospital admission
RI
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-DO
NOT
ALTER
Short-acting inhaledbeta2-agonistbronchodilators (SABA)(pMDIs,
DPIs and, rarely,solution for nebulization orinjection) e.g.
salbutamol(albuterol), terbutaline.
TE
Abbreviations used in this pocket guideBeclometasone
dipropionate
BUD
Budesonide
MA
BDP
Dry powder inhaler
FEV1
Forced expiratory volume in 1 second
FVC
Forced vital capacity
IGHTE
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DPI
Inhaled corticosteroids
LABA Long-acting beta2-agonistsO2
Oxygen
Oral corticosteroids
PYR
OCSPEF
Peak expiratory flow
pMDI
Pressurized metered dose inhaler
CO
SABA Short-acting beta2-agonists
27
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ACKNOWLEDGEMENTS
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The activities of the Global Initiative of Asthma are supported
by the work of membersof the GINA Board of Directors and Committees
(listed below). The work was alsosupported in 20122013 by
unrestricted educational grants from the followingcompanies:
Almirall, Boehringer Ingelheim, Boston Scientific, CIPLA, Chiesi,
ClementClarke, GlaxoSmithKline, Merck Sharp & Dohme, Novartis
and Takeda.
REP
The members of the GINA committees are solely responsible for
the statements andrecommendations presented in this and other GINA
publications.
GINA Board of Directors (2014)
OR
J Mark FitzGerald, Canada, Chair; Eric Bateman, South Africa;
Louis-Philippe Boulet*,Canada; Alvaro Cruz*, Brazil; Tari
Haahtela*, Finland; Mark Levy*, United Kingdom;Paul O'Byrne,
Canada; Pierluigi Paggiaro*, Italy; Soren Pedersen, Denmark;
ManuelSoto-Quiroz*, Costa Rica; Helen Reddel, Australia; Gary
Wong*, Hong Kong ROC.
ALTER
GINA Scientific Director: Suzanne Hurd, USAGINA Science
Committee (2014)
NOT
Helen Reddel, Australia, Chair; Eric Bateman, South Africa.;
Allan Becker, Canada ;Johan de Jongste, The Netherlands; Jeffrey M.
Drazen, USA ; J. Mark FitzGerald,Canada; Hiromasa Inoue, Japan;
Robert Lemanske, Jr., USA; Paul O'Byrne, Canada;Soren Pedersen,
Denmark; Emilio Pizzichini, Brazil; Stanley J. Szefler,
USA.Consultant to the Science Committee: Brian Rowe, Canada.
GINA Dissemination and Implementation Committee (2014)
-DO
Louis-Philippe Boulet, Canada, Chair; other members indicated by
asterisks (*) above.
GINA Assembly
RI
GINA PUBLICATIONS
AL
The GINA Assembly includes members from 45 countries. Their
names are listed onthe GINA website, www.ginasthma.org.
MA
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Global Strategy for Asthma Management and Prevention (2014).
This majorrevision provides an integrated approach to asthma that
can be adapted for a widerange of health systems. The report has a
user-friendly format with practicalsummary tables and flow-charts
for use in clinical practice.GINA Online Appendix. Detailed
background information to support the main report.
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Pocket Guide for asthma management and prevention for adults and
childrenolder than 5 years (2014). Summary for primary health care
providers, to be used inconjunction with the main GINA
report.Pocket guide for asthma management and prevention in
children 5 years andyounger (2014). A summary of patient care
information about pre-schoolers withasthma or wheeze, to be used in
conjunction with the main GINA 2014 report.Diagnosis of asthma-COPD
overlap syndrome (ACOS) (2014). This is a standalone copy of the
corresponding chapter in the main GINA report. It is co-publishedby
GINA and GOLD (the Global Initiative for Chronic Obstructive Lung
Disease,www.goldcopd.org).Clinical practice aids and implementation
tools will be available on the GINAwebsite.GINA publications and
other resources are available from www.ginasthma.org
28
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CERODUREPORALTERNOT-DOALRITEMADIGHTEPYRCO
Visit the GINA website at www.ginasthma.org 2014 Global
Initiative for Asthma