G IN A

1. GINA 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. Classification of Severity CLASSIFY SEVERITY Clinical Features Before Treatment Nocturnal Symptoms FEV1 or PEF Symptoms Continuous Limited physical activity STEP 4 Severe Persistent  60% predicted Variability > 30% Frequent 60 - 80% predicted Variability > 30% STEP 3 Moderate Persistent Daily Attacks affect activity > 1 time week STEP 2 Mild Persistent  80% predicted Variability 20 - 30% > 2 times a month > 1 time a week but < 1 time a day < 1 time a week Asymptomatic and normal PEF between attacks  80% predicted Variability < 20% STEP 1 Intermittent  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. 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. 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 ProgramPart 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. Six-part Asthma Management ProgramPart 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. Six-part Asthma Management ProgramFactors Associated with Non-Compliance in Asthma Care • Patient/Physician • Misunderstanding/lack of information • Underestimation of severity • Attitudes toward ill health • Cultural factors • Poor communication Medication Usage • Difficulties associated with inhalers • Complicated regimens • Fears about, or actual side effects • Cost

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 ProgramPart 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. Six-part Asthma Management ProgramPart 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. 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. 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. 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. Part 4: Long-term Asthma ManagementPharmacologic 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

32. Part 4: Long-term Asthma Management Stepwise Approach to Asthma Therapy - Adults Outcome: BestPossible 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 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 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 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 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 ProgramPart 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 ProgramPart 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 ProgramPart 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 ProgramPart 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. Six-part Asthma Management ProgramPart 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. Six-part Asthma Management ProgramPart 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. Six-part Asthma Management ProgramPart 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. Initial Assessment History, Physical Examination, PEF or FEV1 Initial Therapy Bronchodilators; O2 if needed Good Response Incomplete/Poor Response Observe for at least 1 hour Add Systemic Glucocorticosteroids Good Response Poor Response If Stable, Discharge to Home Discharge Admit to Hospital Emergency Department ManagementAcute Asthma Respiratory Failure Admit to ICU

45. Six-part Asthma Management ProgramPart 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 ProgramSpecial 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

49. http://www.ginasthma.com

50. Part 4: Long-term Asthma Management Stepwise Approach to Asthma Therapy - Adults Outcome: BestPossible 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).