Asthma Management

Guide
British Guideline on the
Management of Asthma
Dr. Thisara
Perera

Burden of asthma
Asthma is one of the most common chronic diseases
worldwide with an estimated 300 million affected individuals
Prevalence is increasing in many countries, especially in
children
Asthma is a major cause of school and work absence
Health care expenditure on asthma is 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 due to
increasing prevalence of asthma
Poorly controlled asthma is expensive
However, investment in prevention medication is likely to yield cost
savings in emergency care

GINA 2014

Prevalence of asthma in children aged

13-14 years

Global
GINA 2014 Appendix Box A1-1; figure provided
by Initiative
R Beasley for Asthma

Global Initiative for Asthma

What is known about asthma?

Asthma is a common and potentially serious chronic
disease that can be controlled but not cured
Asthma causes symptoms such as wheezing, shortness
of breath, chest tightness and cough that vary over
time in their occurrence, frequency and intensity
Symptoms are associated with variable expiratory airflow,
i.e. difficulty breathing air out of the lungs due to
Bronchoconstriction (airway narrowing)
Airway wall thickening
Increased mucus

Symptoms may be triggered or worsened by factors such

as viral infections, allergens, tobacco smoke, exercise and
stress
GINA 2014

What is known about asthma?

Asthma can be effectively treated
When asthma is well-controlled, patients
can
Avoid troublesome symptoms during the day and night
Need little or no reliever medication
Have productive, physically active lives
Have normal or near-normal lung function
Avoid serious asthma flare-ups (also called
exacerbations, or severe attacks)

GINA 2014

Definition of asthma
Asthma is a heterogeneous disease, usually
characterized by chronic airway inflammation.
It is defined by the history of respiratory symptoms such
as wheeze, shortness of breath, chest tightness and
cough that vary over time and in intensity, together
with variable expiratory airflow limitation.

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GINA 2014

DIAGNOSIS IN ADULTS
More than one of the following symptoms: wheeze,
breathlessness,
chest tightness and cough, particularly if:
symptoms worse at night and in the early morning
symptoms in response to exercise, allergen exposure and
cold air
symptoms after taking aspirin or beta blockers
History of atopic disorder
Family history of asthma and/or atopic disorder
Widespread wheeze heard on auscultation of the chest
Otherwise unexplained low FEV1 or PEF (historical or serial
readings)
Otherwise unexplained peripheral blood eosinophilia

Diagnosis of asthma
The diagnosis of asthma should be based on:
A history of characteristic symptom patterns
Evidence of variable airflow limitation, from
bronchodilator reversibility testing or other tests

Document evidence for the diagnosis in the patients

notes, preferably before starting controller treatment
It is often more difficult to confirm the diagnosis after
treatment has been started

Asthma is usually characterized by airway

inflammation and airway hyper-responsiveness, but
these are not necessary or sufficient to make the
diagnosis of asthma.
GINA 2014

Diagnosis of asthma symptoms

Increased probability that symptoms are due to asthma if:
More than one type of symptom (wheeze, shortness of breath, cough,
chest tightness)
Symptoms often worse at night or in the early morning
Symptoms vary over time and in intensity
Symptoms are triggered by viral infections, exercise, allergen
exposure, changes in weather, laughter, irritants such as car exhaust
fumes, smoke, or strong smells

Decreased probability that symptoms are due to asthma if:

Isolated cough with no other respiratory symptoms
Chronic production of sputum
Shortness of breath associated with dizziness, light-headedness or
peripheral tingling
Chest pain
Exercise-induced dyspnea with noisy inspiration (stridor)
GINA 2014

Diagnosis of asthma variable airflow limitation

Confirm presence of airflow limitation
Document that FEV1/FVC is reduced (at least once, when FEV1 is low)
FEV1/ FVC ratio is normally >0.75 0.80 in healthy adults, and
>0.90 in children

Confirm variation in lung function is greater than in healthy individuals

The greater the variation, or the more times variation is seen, the
greater probability that the diagnosis is asthma
Excessive bronchodilator reversibility (adults: increase in FEV 1
>12% and >200mL; children: increase >12% predicted)
Excessive diurnal variability from 1-2 weeks twice-daily PEF
monitoring (daily amplitude x 100/daily mean, averaged)
Significant increase in FEV1 or PEF after 4 weeks of controller
treatment
If initial testing is negative:
Repeat when patient is symptomatic, or after withholding bronchodilators
Refer for additional tests (especially children 5 years, or the elderly)

GINA 2014, Box 1-2

Typical spirometric tracings

Volume

Normal

Flo
w

FEV1
Asthma
(after BD)
Normal
Asthma
(before BD)

Asthma
(after BD)
Asthma
(before BD)

Volume

Time (seconds)
Note: Each FEV1 represents the
highest of three reproducible
measurements
GINA 2014

Global Initiative for Asthma

The role of lung function in asthma

Diagnosis
Demonstrate variable expiratory airflow limitation
Reconsider diagnosis if symptoms and lung function are discordant
Frequent symptoms but normal FEV1: cardiac disease; lack of fitness?
Few symptoms but low FEV1: poor perception; restriction of lifestyle?

Risk assessment
Low FEV1 is an independent predictor of exacerbation risk

Monitoring progress
Measure lung function at diagnosis, 3-6 months after starting
treatment
(to identify personal best), and then periodically
Consider long-term PEF monitoring for patients with severe asthma or
impaired perception of airflow limitation

Adjusting treatment?
Utility of lung function for adjusting treatment is limited by between-visit
variability of FEV1 (15% year-to-year)
GINA 2014

Assessment of asthma
1. Asthma control - two domains
Assess symptom control over the last 4 weeks
Assess risk factors for poor outcomes, including low lung
function

2. Treatment issues

Check inhaler technique and adherence

Ask about side-effects
Does the patient have a written asthma action plan?
What are the patients attitudes and goals for their asthma?

3. Comorbidities
Think of rhinosinusitis, GERD, obesity, obstructive sleep
apnea, depression, anxiety
These may contribute to symptoms and poor quality of life
GINA 2014, Box 2-1

How to distinguish between uncontrolled

and severe asthma

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GINA 2014, Box 2-4

Global Initiative for Asthma

The control-based asthma management cycle

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GINA 2014, Box 3-2

Global Initiative for Asthma

Initial controller treatment for adults,

adolescents and children 611 years
Start controller treatment early
For best outcomes, initiate controller treatment as early as
possible after making the diagnosis of asthma

Indications for regular low-dose ICS - any of:

Asthma symptoms more than twice a month
Waking due to asthma more than once a month
Any asthma symptoms plus any risk factors for exacerbations

Consider starting at a higher step if:

Troublesome asthma symptoms on most days
Waking from asthma once or more a week, especially if any risk factors
for exacerbations

If initial asthma presentation is with an exacerbation:

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Give a short course of oral steroids and start regular controller

treatment (e.g. high dose ICS or medium dose ICS/LABA, then step
down)

GINA 2014, Box 3-4

Supported self
-management
written personalised asthma action
plans

Stepwise management - pharmacotherapy

*For children 6-11 years,

theophylline is not
recommended, and
preferred Step 3 is
medium dose ICS
**For patients prescribed
BDP/formoterol or BUD/
formoterol maintenance
and reliever therapy

GINA 2014, Box 3-5 (upper part)

Global Initiative for Asthma

Step 1 as-needed reliever inhaler

Preferred option: as-needed inhaled short-acting
beta2-agonist (SABA)
SABAs are highly effective for relief of asthma symptoms
However . there is insufficient evidence about the
safety of treating asthma with SABA alone
This option should be reserved for patients with
infrequent symptoms (less than twice a month) of short
duration, and with no risk factors for exacerbations

Other options
Consider adding regular low dose inhaled corticosteroid
(ICS) for patients at risk of exacerbations

GINA 2014

Step 2 Low dose controller +

as-needed SABA
Preferred option: regular low dose ICS with as-needed inhaled
SABA

Low dose ICS reduces symptoms and reduces risk of

exacerbations and asthma-related hospitalization and
death
Other options
Leukotriene receptor antagonists (LTRA) with as-needed SABA
Less effective than low dose ICS
May be used for some patients with both asthma and allergic rhinitis, or if patient
will not use ICS

Combination low dose ICS/long-acting beta2-agonist (LABA)

with as-needed SABA
Reduces symptoms and increases lung function compared with ICS
More expensive, and does not further reduce exacerbations

Intermittent ICS with as-needed SABA for purely seasonal

allergic asthma with no interval symptoms
Start ICS immediately symptoms commence, and continue for
4 weeks after pollen season ends
GINA 2014

Step 3 one or two controllers +

as-needed inhaled reliever
Before considering step-up
Check inhaler technique and adherence, confirm diagnosis

Adults/adolescents: preferred options are either combination low dose

ICS/LABA maintenance with as-needed SABA, OR combination low
dose ICS/formoterol maintenance and reliever regimen*
Adding LABA reduces symptoms and exacerbations and increases FEV 1, while
allowing lower dose of ICS
In at-risk patients, maintenance and reliever regimen significantly reduces
exacerbations with similar level of symptom control and lower ICS doses
compared with other regimens

Children 6-11 years: preferred option is medium dose ICS with

as-needed SABA
Other options
Adults/adolescents: Increase ICS dose or add LTRA or theophylline (less
effective than ICS/LABA)
Children 6-11 years add LABA (similar effect as increasing ICS)
*Approved only for low dose beclometasone/formoterol and low dose
budesonide/formoterol
GINA 2014

Step 4 two or more controllers + as-needed

inhaled reliever
Before considering step-up
Check inhaler technique and adherence

Adults or adolescents: preferred option is combination low

dose ICS/formoterol as maintenance and reliever
regimen*, OR
combination medium dose ICS/LABA with as-needed
SABA
Children 611 years: preferred option is to refer for expert
advice
Other options (adults or adolescents)
Trial of high dose combination ICS/LABA, but little extra benefit and
increased risk of side-effects
Increase dosing frequency (for budesonide-containing inhalers)
Add-on LTRA or low dose theophylline
*Approved only for low dose beclometasone/formoterol and low dose
budesonide/formoterol
GINA 2014

Step 5 higher level care and/or add-on treatment

Preferred option is referral for specialist investigation and
consideration of add-on treatment
If symptoms uncontrolled or exacerbations persist despite Step 4
treatment, check inhaler technique and adherence before
referring
Add-on omalizumab (anti-IgE) is suggested for patients with
moderate or severe allergic asthma that is uncontrolled on
Step 4 treatment

Other add-on treatment options at Step 5 include:

Sputum-guided treatment: this is available in specialized centers;
reduces exacerbations and/or corticosteroid dose
Add-on low dose oral corticosteroids (7.5mg/day
prednisone equivalent): this may benefit some patients, but has
significant systemic side-effects. Assess and monitor for
osteoporosis
GINA 2014

Low, medium and high dose inhaled corticosteroids

Adults and adolescents (12 years)
Inhaled corticosteroid

Total daily dose (mcg)

Low

Medium

High

Beclometasone dipropionate (CFC)

200500

>5001000

>1000

Beclometasone dipropionate (HFA)

100200

>200400

>400

Budesonide (DPI)

200400

>400800

>800

Ciclesonide (HFA)

80160

>160320

>320

Fluticasone propionate (DPI or HFA)

100250

>250500

>500

Mometasone furoate

110220

>220440

>440

4001000

>10002000

>2000

Triamcinolone acetonide

This is not a table of equivalence, but of estimated clinical comparability

Most of the clinical benefit from ICS is seen at low doses
High doses are arbitrary, but for most ICS are those that, with prolonged use,
are associated with increased risk of systemic side-effects
GINA 2014, Box 3-6

Difference between salmetrol and

formetrol
Salmeterol takes about 30 minutes to
start to work. Peak effectiveness
after 3 to 4 hours and lasts for more
than 12 hours.
Formoterol starts within a few
minutes. It lasts for more than 12
hours.

Reviewing response and adjusting treatment

How often should asthma be reviewed?
1-3 months after treatment started, then every 3-12 months
During pregnancy, every 4-6 weeks
After an exacerbation, within 1 week

Stepping up asthma treatment

Sustained step-up, for at least 2-3 months if asthma poorly controlled
Important: first check for common causes (symptoms not due to asthma,
incorrect inhaler technique, poor adherence)

Short-term step-up, for 1-2 weeks, e.g. with viral infection or allergen
May be initiated by patient with written asthma action plan

Day-to-day adjustment
For patients prescribed low-dose ICS/formoterol maintenance and reliever
regimen*

Stepping down asthma treatment

Consider step-down after good control maintained for 3 months
Find each patients minimum effective dose, that controls both
symptoms and exacerbations
*Approved only for low dose beclometasone/formoterol and low dose
budesonide/formoterol
GINA 2014

General principles for stepping down controller

treatment
Aim
To find the lowest dose that controls symptoms and exacerbations, and
minimizes the risk of side-effects

When to consider stepping down

When symptoms have been well controlled and lung function stable for
3 months
No respiratory infection, patient not travelling, not pregnant

Prepare for step-down

Record the level of symptom control and consider risk factors
Make sure the patient has a written asthma action plan
Book a follow-up visit in 1-3 months

Step down through available formulations

Stepping down ICS doses by 2550% at 3 month intervals is feasible and safe
for most patients

Stopping ICS is not recommended in adults with asthma

GINA 2014, Box 3-7

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NON-PHARMACOLOGICAL
MANAGEMENT
Measures to reduce in utero or early
life exposure to single aeroallergens,
such as house dust mites or pets, or
single food allergens, are not
recommended for the primary
prevention of asthma
Insufficient evidence to make maternal dietary supplementation
during pregnancy & the use of
dietary probiotics in pregnancy.

Primary prevention of asthma

The development and persistence of asthma are driven by
gene-environment interactions
For children, a window of opportunity exists in utero and in
early life, but intervention studies are limited
For intervention strategies including allergen avoidance
Strategies directed at a single allergen have not been effective
Multifaceted strategies may be effective, but the essential
components have not been identified

Current recommendations are

Avoid exposure to tobacco smoke in pregnancy and early life

Encourage vaginal delivery
Advise breast-feeding for its general health benefits
Where possible, avoid use of paracetamol (acetaminophen)
and broad-spectrum antibiotics in the first year of life

GINA 2014, Box 7-1

Secondary prevention
1. Physical and chemical methods of
reducing house dust mite levels in
the home not recommended
2.Weight loss
3.Smoking cessation
4.Air ionisers are not recommended
5.Breathing exercise programmes

Investigations in patients with severe asthma

Confirm the diagnosis of asthma
Consider alternative diagnoses or contributors to
symptoms, e.g. upper airway dysfunction, COPD,
recurrent respiratory infections

Investigate for comorbidities

Chronic sinusitis, obesity, GERD, obstructive sleep
apnea, psychological or psychiatric disorders

Check inhaler technique and medication adherence

Investigate for persistent environmental exposure
Allergens or toxic substances (domestic or occupational)

GINA 2014, Box 3-14

Management of severe asthma

Optimize dose of ICS/LABA
Complete resistance to ICS is rare
Consider therapeutic trial of higher dose

Consider low dose maintenance oral corticosteroids

Monitor for and manage side-effects, including osteoporosis

Add-on treatments without phenotyping

Theophylline, LTRA limited benefit
Tiotropium not yet approved for asthma by a major regulator

Phenotype-guided treatment
Sputum-guided treatment to reduce exacerbations and/or steroid dose
Severe allergic asthma: suggest add-on anti-IgE treatment (omalizumab)
Aspirin-exacerbated respiratory disease: consider add-on LTRA

Non-pharmacological interventions
Consider bronchial thermoplasty for selected patients
Comprehensive adherence-promoting program

GINA 2014, Box 3-14 (2/2)

Written asthma action plans

All patients should have a written asthma action plan
The aim is to show the patient how to recognize and respond to
worsening asthma
It should be individualized for the patients medications, level of
asthma control and health literacy
Based on symptoms and/or PEF (children: only symptoms)

The action plan should include:

The patients usual asthma medications
When/how to increase reliever and controller or start OCS
How to access medical care if symptoms fail to respond

Why?
When combined with self-monitoring and regular medical
review, action plans are highly effective in reducing asthma
mortality and morbidity
GINA 2014

Acute asthma

 The aim of oxygen therapy is to

maintain SpO2 94-98%
Patients with SpO2 <92% or other
features of life-threatening asthma
require ABG measurement

C X-ray
Chest X-ray is not routinely
recommended in patients in the
absence of:
- suspected pneumomediastinum or
pneumothorax
- suspected consolidation
- life-threatening asthma
- failure to respond to treatment
satisfactorily
- requirement for ventilation

1.Poor adherence
2.Psychosocial issues
3.consider monitoring induced sputum
eosinophil counts to guide
4.steroid treatment.

Asthma-COPD overlap syndrome

(ACOS)
Patients with features of both asthma and
COPD have worse outcomes than those
with asthma or COPD alone
Concurrent doctor-diagnosed asthma and COPD
are found in
1520% of patients with chronic airways disease

Definitions
Asthma
Asthma is a heterogeneous disease, usually characterized by chronic
chronicairway
airway
inflammation. ItItisisdefined
inflammation.
definedbybythe
thehistory
historyofofrespiratory
respiratorysymptoms
symptomssuch
suchasaswheeze,
wheeze,
shortness of breath, chest tightness and cough that vary
vary over
overtime
timeand
andininintensity,
together with
intensity,
together
variable
with
expiratory
variable
airflow
expiratory
limitation.
airflow
[GINA
limitation.
2014] [GINA 2014]

COPD
COPD is a common preventable and treatable disease, characterized by persistent
airflow limitation
persistent
airflow
thatlimitation
is usuallythat
progressive
is usually
and
progressive
associated with
and enhanced
associated
chronic
with
inflammatory
enhanced
chronic
responses
inflammatory
in the airways
responses
and the in
lungs
the airways
to noxious
andparticles
the lungs
or to
gases.
Exacerbations
noxious
particles
and
orcomorbidities
gases. Exacerbations
contributeand
to the
comorbidities
overall severity
contribute
in individual
to the
patients.
overall
severity
[GOLDin2014]
individual patients. [GOLD 2014]

Asthma-COPD overlap syndrome (ACOS) [a description]

Asthma-COPD overlap syndrome (ACOS) is characterized by persistent airflow
limitation with several features usually associated with asthma and several
features usually associated with COPD. ACOS is therefore identified by the
features that it shares with both asthma and COPD.
GINA 2014, Box 5-1

Global Initiative for Asthma

Step 1 Does the patient have

chronic airways disease?
Clinical history: consider chronic airways disease if
Chronic or recurrent cough, sputum, dyspnea or wheezing,
or repeated acute lower respiratory tract infections
Previous doctor diagnosis of asthma and/or COPD
Previous treatment with inhaled medications
History of smoking tobacco and/or other substances
Exposure to environmental hazards, e.g. airborne pollutants

Physical examination
May be normal
Evidence of hyperinflation or respiratory insufficiency
Wheeze and/or crackles

GINA 2014

Step 1 Does the patient have chronic

airways disease?
Radiology (CXR or CT scan performed for other reasons)
May be normal, especially in early stages
Hyperinflation, airway wall thickening, hyperlucency, bullae
May identify or suggest an alternative or additional
diagnosis, e.g. bronchiectasis, tuberculosis, interstitial lung
disease, cardiac failure

Screening questionnaires
Designed to assist in identification of patients at risk of
chronic airways disease
May not be generalizable to all countries, practice settings
or patients
See GINA and GOLD reports for examples
GINA 2014

Step 2 Syndromic diagnosis of

asthma, COPD and ACOS
Assemble the features that, when present, most
favor a diagnosis of asthma or COPD
Compare the number of features on each side
If the patient has 3 features of either asthma or COPD,
there is a strong likelihood that this is the correct diagnosis

Consider the level of certainty around the diagnosis

Diagnoses are made on the weight of evidence
The absence of any of these typical features does not rule
out either diagnosis, e.g. absence of atopy does not rule
out asthma
When a patient has a similar number of features of both
asthma and COPD, consider the diagnosis of ACOS
GINA 2014

GINA
2014, Box 5-4
GINA
2014

Global Initiative for Asthma

Step 3 - Spirometry
Essential if chronic airways disease is suspected
Confirms chronic airflow limitation
More limited value in distinguishing between asthma with
fixed airflow limitation, COPD and ACOS

Measure at the initial visit or subsequent visit

If possible measure before and after a trial of treatment
Medications taken before testing may influence results

Peak expiratory flow (PEF)

Not a substitute for spirometry
Normal PEF does not rule out asthma or COPD
Repeated measurement may confirm excessive
variability, found in asthma or in some patients with ACOS
GINA 2014, Box 5-3

Step 3 - Spirometry
Spirometric variable
Normal FEV1/FVC
pre-or post-BD

Asthma

COPD

Compatible with asthma

Not compatible with
diagnosis (GOLD)

ACOS
Not compatible unless
other evidence of chronic
airflow limitation

Post-BD FEV1/FVC <0.7 Indicatesairflow

Required for diagnosis Usual in ACOS
limitation; may improve by GOLDcriteria
FEV1=80% predicted Compatible with asthma o
Cmpatible with GOLD Compatible with mild
(good control, or interval
category A or B if post
ACOS
between symptoms)
BD FEV1/FVC <0.7
FEV1<80% predicted Compatible with asthma.
Indicates severity of Indicates severity of
A risk factor for
airflow limitation and risk
airflow limitation and risk
exacerbations
of exacerbations and of exacerbations and
mortality
mortality
PostBD increase in
Usual at some time in Common in COPD and Common in ACOS, and
FEV>12%
and 200mL course
of asthma; not more likely when FEV
1
1 is more likely when FEV
1 is
from baseline (reversible
always present
low, but consider ACOS low
airflow limitation)
PostBD increase in
High probability of
FEV>12%
and 400mLasthma
1
from baseline
GINA 2014, Box 5-3

Unusual in COPD.
Consider ACOS

Compatible with
diagnosis of ACOS
Global Initiative for Asthma

Step 4 Commence initial therapy

Initial choices based on syndromic assessment and spirometry
If features are consistent with asthma, treat as asthma
If features are consistent with COPD, treat as COPD
If syndromic assessment suggests ACOS, or there is significant
uncertainty about the diagnosis of COPD, start treatment as for
asthma pending further investigation

Consider both efficacy and safety

If any features of asthma, do not prescribe LABA without ICS
If any features of COPD, give symptomatic treatment with
bronchodilators or combination therapy, but not ICS alone
If ACOS, give ICS and consider LABA and/or LAMA

Other important strategies for ACOS and COPD

Non-pharmacological strategies including smoking cessation,
pulmonary rehabilitation, vaccinations, treatment of comorbidities
GINA 2014

Step 5 Refer for specialized investigations if

needed
Refer for expert advice and extra investigations if patient has:
Persistent symptoms and/or exacerbations despite treatment
Diagnostic uncertainty, especially if alternative diagnosis
(e.g. TB, cardiovascular disease) needs to be excluded
Suspected airways disease with atypical or additional symptoms or
signs (e.g. hemoptysis, weight loss, night sweats, fever, chronic
purulent sputum). Do not wait for a treatment trial before referring
Suspected chronic airways disease but few features of
asthma, COPD or ACOS
Comorbidities that may interfere with their management
Issues arising during on-going management of asthma, COPD or
ACOS

GINA 2014