G lobal

INitiative for
A sthma
© Global Initiative for Asthma
 Definition of Asthma

 A chronic inflammatory disorder of the airways

 Many cells and cellular elements play a role
 Chronic inflammation is associated with airway
hyperresponsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest
tightness, and coughing
 Widespread, variable, and often reversible
airflow limitation
© Global Initiative for Asthma
Mechanisms: Asthma Inflammation

Source: Peter J. Barnes, MD

Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, MD

 Burden of Asthma

 Asthma is one of the most common chronic

diseases worldwide with an estimated 300
million affected individuals
 Prevalence increasing in many countries,
especially in children
 A major cause of school/work absence

© Global Initiative for Asthma

Asthma Prevalence and Mortality

Source: Masoli M et al. Allergy 2004

 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

© Global Initiative for Asthma

 Factors that Exacerbate Asthma

 Allergens
 Respiratory infections
 Exercise and hyperventilation
 Weather changes
 Sulfur dioxide
 Food, additives, drugs

© Global Initiative for Asthma

 Factors that Influence Asthma
Development and Expression

Host Factors Environmental Factors

 Genetic  Indoor allergens

 Outdoor allergens
- Atopy
 Occupational sensitizers
- Airway
 Tobacco smoke
hyperresponsiveness
 Air Pollution
 Gender
 Respiratory Infections
 Obesity  Diet

© Global Initiative for Asthma

 Asthma Diagnosis
 History and patterns of symptoms
 Measurements of lung function
- Spirometry
- Peak expiratory flow
 Measurement of airway responsiveness
 Measurements of allergic status to identify risk
factors
 Extra measures may be required to diagnose
asthma in children 5 years and younger and the
elderly © Global Initiative for Asthma
 Typical Spirometric (FEV11)
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
© Global Initiative for Asthma
 Asthma Management and Prevention
Program: Five Interrelated Components

1. Develop Patient/Doctor Partnership

2. Identify and Reduce Exposure to
Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
5. Special Considerations
© Global Initiative for Asthma
 Asthma
Asthma Management
Management and
and Prevention
Prevention Program
Program
Component 1: Develop
Patient/Doctor 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

© Global Initiative for Asthma

 Asthma Management and Prevention Program
Component 2: Identify and Reduce
Exposure to Risk Factors

 Measures to prevent the development of asthma,

and asthma exacerbations by avoiding or reducing
exposure to risk factors should be implemented
wherever possible.
 Asthma exacerbations may be caused by a variety
of risk factors – allergens, viral infections,
pollutants and drugs.
 Reducing exposure to some categories of risk
factors improves the control of asthma and
reduces medications needs.
© Global Initiative for Asthma
 Asthma Management and Prevention Program
Component 2: Identify and Reduce
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
© Global Initiative for Asthma
 Asthma Management and Prevention Program
Influenza Vaccination

 Influenza vaccination should be

provided to patients with asthma when
vaccination of the general population is
advised
 However, routine influenza vaccination
of children and adults with asthma
does not appear to protect them from
asthma exacerbations or improve
asthma control
© Global Initiative for Asthma
 Asthma Management
Management and
and Prevention
Prevention Program
Component 3: Assess, Treat
and Monitor Asthma

The goal of asthma treatment, to

achieve and maintain clinical
control, can be achieved in a
majority of patients with a
pharmacologic intervention strategy
developed in partnership between
the patient/family and the health
care professional
© Global Initiative for Asthma
 Global Strategy for Asthma Management and Prevention

Clinical Control of Asthma

The focus on asthma control is

important because:
 the attainment of control correlates
with a better quality of life, and
 reduction in health care use
© Global Initiative for Asthma
 Global Strategy for Asthma Management and Prevention

Clinical Control of Asthma

 Determine the initial level of

control to implement treatment
(assess patient impairment)

 Maintain control once treatment

has been implemented
(assess patient risk)
© Global Initiative for Asthma
 Levels of Asthma Control
(Assess patient impairment)

Assessment of Future Risk (risk of exacerbations, instability, rapid

decline in lung function, side effects)
© Global Initiative for Asthma
 Assess Patient Risk

Features that are associated with increased

risk of adverse events in the future include:
 Poor clinical control
 Frequent exacerbations in past year
 Ever admission to critical care for asthma

Low FEV1, exposure to cigarette smoke, high

dose medications
© Global Initiative for Asthma
 Asthma Management and Prevention Program

Component 3: Assess, Treat

and Monitor Asthma
The choice of treatment should be guided by:
 Level of asthma control
 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
© Global Initiative for Asthma
 Controller Medications
 Inhaled glucocorticosteroids
 Leukotriene modifiers

 Long-acting inhaled β2-agonists in combination

with inhaled glucocorticosteroids
 Systemic glucocorticosteroids

 Theophylline

 Cromones

 Anti-IgE

© Global Initiative for Asthma

 Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age

Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
Beclomethasone 200-500 100-200 >500-1000 >200-400 >1000 >400

Budesonide 200-600 100- 600-1000 >200-400 >1000 >400

200

Budesonide-Neb 250- 500-1000 >1000

Inhalation Suspension 500
Ciclesonide 80 – 160 80-160 >160-320 >160-320 >320-1280 >320
Flunisolide 500-1000 500- >1000-2000 >750-1250 >2000 >1250
750
Fluticasone 100-250 100- >250-500 >200-500 >500 >500
200
Mometasone furoate 200-400 100- > 400-800 >200-400 >800-1200 >400
200
Triamcinolone acetonide 400-1000 400- >1000-2000 >800-1200 >2000 >1200
800

© Global Initiative for Asthma

 Reliever Medications

 Rapid-acting inhaled β2-agonists

 Systemic glucocorticosteroids
 Anticholinergics
 Theophylline
 Short-acting oral β2-agonists

© Global Initiative for Asthma

 Component 4: Asthma Management and Prevention Program

Allergen-specific Immunotherapy
 Greatest benefit of specific immunotherapy
using allergen extracts has been obtained in
the treatment of allergic rhinitis
 The role of specific immunotherapy in asthma is
limited
 Specific immunotherapy should be considered
only after strict environmental avoidance and
pharmacologic intervention, including inhaled
glucocorticosteroids, have failed to control
asthma
 Perform only by trained physician
© Global Initiative for Asthma
 REDUCE
LEVEL OF CONTROL TREATMENT OF ACTION

maintain and find lowest

controlled
controlling step
consider stepping up to
partly controlled gain control

INCREASE
uncontrolled step up until controlled

exacerbation treat as exacerbation

REDUCE INCREASE
TREATMENT STEPS
STEP STEP STEP STEP STEP
1 2 3 4 5
© Global Initiative for Asthma
 TO STEP 3 TREATMENT, TO STEP 4 TREATMENT,
SELECT ONE OR MORE: ADD EITHER

Shaded green - preferred controller options

 TO STEP 3 TREATMENT, TO STEP 4 TREATMENT,
SELECT ONE OR MORE: ADD EITHER

Shaded green - preferred controller options

 Treating to Achieve Asthma Control

Step 1 – As-needed reliever medication

 Patients with occasional daytime symptoms of
short duration
 A rapid-acting inhaled β2-agonist is the
recommended reliever treatment (Evidence A)
 When symptoms are more frequent, and/or
worsen periodically, patients require regular
controller treatment (step 2 or higher)
© Global Initiative for Asthma
 TO STEP 3 TREATMENT, TO STEP 4 TREATMENT,
SELECT ONE OR MORE: ADD EITHER

Shaded green - preferred controller options

 Treating to Achieve Asthma Control

Step 2 – Reliever medication plus a single

controller
 A low-dose inhaled glucocorticosteroid is
recommended as the initial controller
treatment for patients of all ages (Evidence
A)
 Alternative controller medications include
leukotriene modifiers (Evidence A)
appropriate for patients unable/unwilling to
© Global Initiative for Asthma
 TO STEP 3 TREATMENT, TO STEP 4 TREATMENT,
SELECT ONE OR MORE: ADD EITHER

Shaded green - preferred controller options

 Treating to Achieve Asthma Control

Step 3 – Reliever medication plus one or two

controllers
 For adults and adolescents, combine a low-dose
inhaled glucocorticosteroid with an inhaled long-
acting β2-agonist either in a combination inhaler
device or as separate components (Evidence A)
 Inhaled long-acting β2-agonist must not be used
as monotherapy
 For children, increase to a medium-dose inhaled
glucocorticosteroid (Evidence A)
© Global Initiative for Asthma
 Treating to Achieve Asthma Control

Additional Step 3 Options for Adolescents and Adults

 Increase to medium-dose inhaled

glucocorticosteroid (Evidence A)
 Low-dose inhaled glucocorticosteroid
combined with leukotriene modifiers
(Evidence A)
 Low-dose sustained-release theophylline
(Evidence B)
© Global Initiative for Asthma
 TO STEP 3 TREATMENT, TO STEP 4 TREATMENT,
SELECT ONE OR MORE: ADD EITHER

Shaded green - preferred controller options

 Treating to Achieve Asthma Control

Step 4 – Reliever medication plus two or more

controllers
 Selection of treatment at Step 4 depends
on prior selections at Steps 2 and 3
 Where possible, patients not controlled on
Step 3 treatments should be referred to a
health professional with expertise in the
management of asthma
© Global Initiative for Asthma
 Treating to Achieve Asthma Control

Step 4 – Reliever medication plus two or more controllers

 Medium- or high-dose inhaled glucocorticosteroid

combined with a long-acting inhaled β2-agonist
(Evidence A)
 Medium- or high-dose inhaled glucocorticosteroid
combined with leukotriene modifiers (Evidence A)
 Low-dose sustained-release theophylline added
to medium- or high-dose inhaled
glucocorticosteroid combined with a long-acting
inhaled β2-agonist (Evidence B)
© Global Initiative for Asthma
 TO STEP 3 TREATMENT, TO STEP 4 TREATMENT,
SELECT ONE OR MORE: ADD EITHER

Shaded green - preferred controller options

 Treating to Achieve Asthma Control

Step 5 – Reliever medication plus additional controller options

 Addition of oral glucocorticosteroids to other

controller medications may be effective
(Evidence D) but is associated with severe
side effects (Evidence A)
 Addition of anti-IgE treatment to other
controller medications improves control of
allergic asthma when control has not been
achieved on other medications (Evidence A)
© Global Initiative for Asthma
 Asthma Management
Management and
and Prevention
Prevention Program
Component 4: Manage Asthma
Exacerbations

 Exacerbations of asthma are episodes of

progressive increase in shortness of breath,
cough, wheezing, or chest tightness
 Exacerbations are characterized by decreases
in expiratory airflow that can be quantified and
monitored by measurement of lung function
(FEV1 or PEF)
 Severe exacerbations are potentially life-
threatening and treatment requires close
supervision
© Global Initiative for Asthma
 Asthma Management
Management and
and Prevention
Prevention Program
Component 4: Manage Asthma
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
© Global Initiative for Asthma
 Asthma Management
Management and
and Prevention
Prevention Program
Component 4: Manage Asthma
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
© Global Initiative for Asthma
 Asthma
Asthma Management
Management and
and Prevention
Prevention Program
Program
Special Considerations
Special considerations are required to
manage asthma in relation to:
 Pregnancy
 Surgery
 Rhinitis, sinusitis, and nasal polyps
 Occupational asthma
 Respiratory infections
 Gastroesophageal reflux
 Aspirin-induced asthma
 Anaphylaxis and Asthma
© Global Initiative for Asthma