POCKET GUIDE FOR ASTHMA MANAGEMENT AND PREVENTION

POCKET GUIDE FOR
ASTHMA MANAGEMENT
AND PREVENTION
A Pocket Guide for Health Professionals
Updated 2016
(for Adults and Children Older than 5 Years)
BASED ON THE GLOBAL STRATEGY FOR ASTHMA
MANAGEMENT AND PREVENTION
© Global Initiative for AsthmaCOPYRIGHTED MATERIAL- DO NOT ALTER OR REPRODUCE

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GLOBAL INITIATIVE
FOR ASTHMA
POCKET GUIDE FOR HEALTH PROFESSIONALS
Updated 2016
GINA Board of Directors
Chair: J Mark FitzGerald, MD
GINA Science Committee
Chair: Helen Reddel, MBBS PhD
GINA Dissemination and Implementation Committee
Chair: Louis-Philippe Boulet, MD
GINA Assembly
The GINA Assembly includes members from 45 countries, listed on the
GINA website www.ginasthma.org .
GINA Program
Suzanne Hurd, PhD (to Dec 2015); Rebecca Decker, BS, MSJ
Names of members of the GINA Committees are listed on page 28. COPYRIGHTED MATERIAL- DO NOT ALTER OR REPRODUCE

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TABLE OF CONTENTS
Preface ............................................................................................................ 3
What is known about asthma? ......................................................................... 4
Making the diagnosis of asthma ...................................................................... 5
Criteria for making the diagnosis of asthma ................................................ 6
Diagnosing asthma in special populations .................................................. 7
Assessing a patient with asthma ...................................................................... 8
How to assess asthma control .................................................................... 9
How to investigate uncontrolled asthma.................................................... 10
Management of asthma ................................................................................. 11
General principles ..................................................................................... 11
Treating to control symptoms and minimize risk ....................................... 11
Control-based asthma management ......................................................... 12
Initial controller treatment .......................................................................... 13
Stepwise approach for adjusting treatment ............................................... 16
Reviewing response and adjusting treatment ........................................... 17
Inhaler skills and adherence ..................................................................... 18
Treating modifiable risk factors ................................................................. 19
Non-pharmacological strategies and interventions ................................... 19
Treatment in special populations or contexts ............................................ 20
Asthma flare-ups (exacerbations) .................................................................. 21
Written asthma action plans ...................................................................... 22
Managing exacerbations in primary or acute care .................................... 23
Reviewing response .................................................................................. 23
Follow-up after an exacerbation ................................................................ 25
Glossary of asthma medication classes ......................................................... 26
Acknowledgements ........................................................................................ 28
GINA publications .......................................................................................... 28


TABLE OF FIGURES
Box 1. Diagnostic flow-chart for asthma in clinical practice ........................... 5

Box 2. Features used in making the diagnosis of asthma ............................. 6
Box 3. How to assess a patient with asthma ................................................. 8
Box 4. Assessment of symptom control and future risk ................................ 9
Box 5. How to investigate uncontrolled asthma in primary care .................. 10
Box 6. The control-based asthma management cycle ................................ 12
Box 7. Stepwise approach to asthma treatment ......................................... 14
Box 8. Low, medium and high daily doses of inhaled corticosteroids ......... 14
Box 9. Self-management with a written action plan .................................... 22
Box 10. Management of asthma exacerbations in primary care ................... 24


Abbreviations used in this Pocket Guide are found on page 27
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PREFACE
Asthma affects an estimated 300 million individuals worldwide. It is a serious
global health problem affecting all age groups, with increasing prevalence in
many developing countries, rising treatment costs, and a rising burden for
patients and the community. Asthma still imposes an unacceptable burden on
health care systems, and on society through loss of productivity in the
workplace and, especially for pediatric asthma, disruption to the family.
Health care providers managing asthma face different issues around the
world, depending on the local context, the health system, and access to
resources.
The Global Initiative for Asthma (GINA) was established to increase
awareness about asthma among health professionals, public health
authorities and the community, and to improve prevention and management
through a coordinated worldwide effort. GINA prepares scientific reports on
asthma, encourages dissemination and implementation of the
recommendations, and promotes international collaboration on asthma
research.
The Global Strategy for Asthma Management and Prevention was
extensively revised in 2014 to provide a comprehensive and integrated
approach to asthma management that can be adapted for local conditions
and for individual patients. It focuses not only on the existing strong evidence
base, but also on clarity of language and on providing tools for feasible
implementation in clinical practice. The report has been updated each year
since then.
The GINA 2016 report and other GINA publications listed on page 28 can be
obtained from www.ginasthma.org
.

The reader acknowledges that this Pocket Guide is a brief summary of the
GINA 2016 report for primary health care providers. It does NOT contain all of
the information required for managing asthma, for example, about safety of
treatments, and it should be used in conjunction with the full GINA 2016
report and with the health professional’s own clinical judgment. GINA cannot
be held liable or responsible for healthcare administered with the use of this
document, including any use which is not in accordance with applicable local
or national regulations or guidelines.

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WHAT IS KNOWN ABOUT ASTHMA?
Asthma is a common and potentially serious chronic disease that
imposes a substantial burden on patients, their families and the community. It
causes respiratory symptoms, limitation of activity, and flare- ups (attacks) that
sometimes require urgent health care and may be fatal.
Fortunately…asthma can be effectively treated, and most patients can
achieve good control of their asthma. When asthma is under good control,
patients can:
 Avoid troublesome symptoms during 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 (exacerbations, or attacks)
What is asthma? Asthma causes symptoms such as wheezing, shortness of
breath, chest tightness and cough that vary over time in their occurrence,
frequency and intensity.
These symptoms are associated with variable expiratory airflow, i.e. difficulty
breathing air out of the lungs due to bronchoconstriction (airway narrowing),
airway wall thickening, and increased mucus. Some variation in airflow can
also occur in people without asthma, but it is greater in asthma.
Factors that may trigger or worsen asthma symptoms include viral
infections, domestic or occupational allergens (e.g. house dust mite, pollens,
cockroach), tobacco smoke, exercise and stress. These responses are more
likely when asthma is uncontrolled. Some drugs can induce or trigger asthma,
e.g. beta-blockers, and (in some patients), aspirin or other NSAIDs.
Asthma flare-ups (also called exacerbations or attacks) may occur even in
people taking asthma treatment. When asthma is uncontrolled, or in some
high-risk patients, these episodes are more frequent and more severe, and
may be fatal.
A stepwise approach to treatment, customized to the individual patient,
takes into account the effectiveness of available medications, their safety, and
their cost to the payer or patient.
Regular controller treatment, particularly with inhaled corticosteroid (ICS) -
containing medications, markedly reduces the frequency and severity of
asthma symptoms and the risk of having a flare- up.
Asthma is a common condition, affecting all levels of society. Olympic
athletes, famous leaders and celebrities, and ordinary people live successful
and active lives with asthma.
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MAKING THE DIAGNOSIS OF ASTHMA
Asthma is a disease with many variations (heterogeneous), usually
characterized by chronic airway inflammation. Asthma has two key defining
features:
• a history of respiratory symptoms such as wheeze, shortness of breath,
chest tightness and cough that vary over time and in intensity, AND
• variable expiratory airflow limitation.
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.
Box 1. Diagnostic flow-chart for asthma in clinical practice


The diagnosis of asthma should be confirmed and, for future reference, the
evidence documented in the patient’s notes. Depending on clinical urgency
and access to resources, this should preferably be done before starting
controller treatment. Confirming the diagnosis of asthma is more difficult after
treatment has been started (see p7 ). COPYRIGHTED MATERIAL- DO NOT ALTER OR REPRODUCE

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CRITERIA FOR MAKING THE DIAGNOSIS OF ASTHMA
Box 2. Features used in making the diagnosis of asthma
1. A history of variable respiratory symptoms
Typical symptoms are wheeze, shortness of breath, chest tightness, cough
• People with asthma generally have more than one of these symptoms
• The symptoms occur variably over time and vary in intensity
• The symptoms often occur or are worse at night or on waking
• Symptoms are often triggered by exercise, laughter, allergens or cold air
• Symptoms often occur with or worsen with viral infections
2. Evidence of variable expiratory airflow limitation
• At least once during the diagnostic process when FEV1 is low,
document that the FEV
1/FVC ratio is reduced. The FEV1/FVC ratio is
normally more than 0.75– 0.80 in adults, and more than 0.90 in children.
• Document that variation in lung function is greater than in healthy
people. For example: o FEV1 increases by more than 12% and 200mL (in children, >12%
of the predicted value) after inhaling a bronchodilator. This is
called ‘bronchodilator reversibility’.
o Average daily diurnal PEF variability* is >10% (in children, >13%)
o FEV
1 increases by more than 12% and 200mL from baseline (in
children, by >12% of the predicted value) after 4 weeks of anti-
inflammatory 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
• Testing may need to be repeated during symptoms, in the early morning, or after withholding bronchodilator medications.
• Bronchodilator reversibility may be absent during severe exacerbations or viral infections. If bronchodilator