Bronchial Asthma

BRONCHIAL ASTHMA
Renato C. Galvan Jr.

Clinical Clerk
ANGELES UNIVERSITY FOUNDATION MEDICAL CENTER
Department of Internal Medicine
DISCLAIMER
Many of the slides in this presentation were taken from the

TEACHING SLIDE SET 2016 UPDATE from the Global Initiative
for Asthma (GINA) webpage, available at http://ginasthma.org/
The presenter made efforts to contact the authors of the slides
for permission to use in academic discourse.
No copyright infringement intended.
Global Initiative for Asthma (GINA)

2016 Update
Global Initiative for Asthma
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 2016
GINA Global Strategy for Asthma Management

and Prevention
Not a guideline, but a practical approach to managing asthma

in clinical practice
A global strategy, relevant to both low and high resource
countries
Evidence-based and clinically-oriented
Provides clinical tools and measurable outcomes
GINA 2016
Global Strategy for Asthma Management &

Prevention 2016
Evidence
category
Sources of evidence
Well-designed RCTs or meta-analyses

Consistent pattern of findings in the population for which the
recommendation is made
Substantial numbers of large studies
Limited number of patients, post hoc or sub-group analyses of

RCTs or meta-analyses
Few RCTs, or small in size, or differing population, or results

somewhat inconsistent
Uncontrolled or non-randomized studies

Observational studies
D
GINA 2016
Panel consensus based on clinical experience or knowledge
DIAGNOSIS and DEFINITION

OF ASTHMA
2016 GINA Update
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 2016
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 2016
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.
GINA 2016
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 hyperresponsiveness, but these are not necessary or
sufficient to make the diagnosis of asthma.
GINA 2016
Patient with
respiratory symptoms
Are the symptoms typical of asthma?
NO
YES
Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Clinical urgency, and
other diagnoses unlikely
Further history and tests for

alternative diagnoses
NO
Alternative diagnosis confirmed?
YES
Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?
NO
YES
Repeat on another
occasion or arrange
other tests
NO
Confirms asthma diagnosis?

Empiric treatment with
ICS and prn SABA
YES
Review response
YES
Consider trial of treatment for

most likely diagnosis, or refer
for further investigations
Diagnostic testing
within 1-3 months
Treat for ASTHMA
GINA 2016, Box 1-1 (4/4)
NO
Treat for alternative diagnosis

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 2016
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 FEV1 >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 2016, Box 1-2
Typical spirometric tracings

Volume
Normal
Flow
FEV1
Asthma
(after BD)
Normal
Asthma
(before BD)
Asthma
(after BD)
Asthma
(before BD)
1
Time (seconds)
Note: Each FEV1 represents the highest of
three reproducible measurements
GINA 2016
Volume
Diagnosis of asthma physical examination
Physical examination in people with asthma

Often normal
The most frequent finding is wheezing on auscultation, especially
on forced expiration
Wheezing is also found in other conditions, for example:
Respiratory infections
COPD
Upper airway dysfunction
Endobronchial obstruction
Inhaled foreign body
Wheezing may be absent during severe asthma exacerbations

(silent chest)
GINA 2016
ASSESSMENT OF ASTHMA
2016 GINA Update
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
3.
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?
Comorbidities
Think of rhinosinusitis, GERD, obesity, obstructive sleep apnea,
depression, anxiety
These may contribute to symptoms and poor quality of life
GINA 2016, Box 2-1
GINA assessment of symptom control

Level of asthma symptom control
A. Symptom control
In the past 4 weeks, has the patient had:
Daytime asthma symptoms more
than twice a week?
Yes No
Any night waking due to asthma?
Yes No
Reliever needed for symptoms*

more than twice a week?
Yes No
Wellcontrolled
Partly
controlled
Uncontrolled
None of
these
1-2 of
these
3-4 of
these
Any activity limitation due to asthma? Yes No
*Excludes reliever taken before exercise, because many people take this routinely
This classification is the same as the GINA 2010-12

assessment of current control, except that lung function
now appears only in the assessment of risk factors
GINA 2016, Box 2-2A
GINA assessment of symptom control

Level of asthma symptom control
A. Symptom control
In the past 4 weeks, has the patient had:
Daytime asthma symptoms more
than twice a week?
Yes No
Any night waking due to asthma?
Yes No
Reliever needed for symptoms*

more than twice a week?
Yes No
Wellcontrolled
Partly
controlled
Uncontrolled
None of
these
1-2 of
these
3-4 of
these
Any activity limitation due to asthma? Yes No
B. Risk factors for poor asthma outcomes
Assess risk factors at diagnosis and periodically

Measure FEV1 at start of treatment, after 3 to 6 months of treatment to record the patients
personal best, then periodically for ongoing risk assessment
ASSESS PATIENTS RISKS FOR:
Exacerbations
Fixed airflow limitation
Medication side-effects
GINA 2016 Box 2-2B (1/4)
Assessment of risk factors for poor asthma

outcomes
Risk factors for exacerbations include:
Ever intubated for asthma

Uncontrolled asthma symptoms
Having 1 exacerbation in last 12 months
Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)
Incorrect inhaler technique and/or poor adherence
Smoking
Obesity, pregnancy, blood eosinophilia
Risk factors for fixed airflow limitation include:

No ICS treatment, smoking, occupational exposure, mucus
hypersecretion, blood eosinophilia
Risk factors for medication side-effects include:

Frequent oral steroids, high dose/potent ICS, P450 inhibitors
GINA 2016, Box 2-2B (4/4)
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 2016
Assessing asthma severity
How?
Asthma severity is assessed retrospectively from the level of
treatment required to control symptoms and exacerbations
When?
Assess asthma severity after patient has been on controller
treatment for several months
Severity is not static it may change over months or years, or as
different treatments become available
Categories of asthma severity

Mild asthma: well-controlled with Steps 1 or 2 (as-needed SABA or
low dose ICS)
Moderate asthma: well-controlled with Step 3 (low-dose ICS/LABA)
Severe asthma: requires Step 4/5 (moderate or high dose
ICS/LABA add-on), or remains uncontrolled despite this treatment
GINA 2016
How to distinguish between uncontrolled

and severe asthma
Watch patient using their
inhaler. Discuss adherence
and barriers to use
Compare inhaler technique with a devicespecific checklist, and correct errors;

recheck frequently. Have an empathic
discussion about barriers to adherence.
Confirm the diagnosis

of asthma
If lung function normal during symptoms,

consider halving ICS dose and repeating
lung function after 23 weeks.
Remove potential
risk factors. Assess and
manage comorbidities
Check for risk factors or inducers such as

smoking, beta-blockers, NSAIDs, allergen
exposure. Check for comorbidities such as
rhinitis, obesity, GERD, depression/anxiety.
Consider treatment
step-up
Consider step up to next treatment level.

Use shared decision-making, and balance
potential benefits and risks.
Refer to a specialist or
severe asthma clinic
GINA 2016, Box 2-4 (5/5)
If asthma still uncontrolled after 36 months

on Step 4 treatment, refer for expert advice.
Refer earlier if asthma symptoms severe,
or doubts about diagnosis.
TREATING ASTHMA
TO CONTROL SYMPTOMS AND
MINIMIZE RISK
2016 GINA Update
Goals of asthma management
The long-term goals of asthma management are

1. Symptom control: to achieve good control of symptoms and
maintain normal activity levels
2. Risk reduction: to minimize future risk of exacerbations, fixed
airflow limitation and medication side-effects
Achieving these goals requires a partnership between patient

and their health care providers
Ask the patient about their own goals regarding their asthma
Good communication strategies are essential
Consider the health care system, medication availability, cultural
and personal preferences and health literacy
GINA 2016
Key strategies to facilitate good communication
Improve communication skills
Friendly manner
Allow the patient to express their goals, beliefs and concerns
Empathy and reassurance
Encouragement and praise
Provide appropriate (personalized) information
Feedback and review
Benefits include:
Increased patient satisfaction
Better health outcomes
Reduced use of health care resources
GINA 2016, Box 3-1
Reducing the impact of impaired health literacy
Health literacy affects health outcomes, including in asthma

The degree to which individuals have the capacity to obtain,
process and understand basic health information and services to
make appropriate health decisions (Rosas-Salazar, JACI 2012)
Strategies for reducing the impact of impaired health literacy
Prioritize information (most important to least important)

Speak slowly, avoid medical language, simplify numeric concepts
Use anecdotes, drawings, pictures, tables and graphs
Use the teach-back method ask patients to repeat instructions
Ask a second person to repeat the main messages
Pay attention to non-verbal communication
GINA 2016, Box 3-1
Treating to control symptoms and minimize risk
Establish a patient-doctor partnership

Manage asthma in a continuous cycle:
Assess
Adjust treatment (pharmacological and
non-pharmacological)
Review the response
Teach and reinforce essential skills

Inhaler skills
Adherence
Guided self-management education
Written asthma action plan
Self-monitoring
Regular medical review
GINA 2016
The control-based asthma management cycle
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
GINA 2016, Box 3-2
Choosing between controller options

population-level decisions
Choosing between treatment options at a population level
e.g. national formularies, health maintenance organisations, national guidelines
The preferred treatment at each step is based on:
Efficacy
based on group mean data for symptoms, exacerbations and
Effectiveness
lung function (from RCTs, pragmatic studies and observational
data)
Safety
Availability and cost at the population level
GINA 2016, Box 3-3 (1/2) Provided by H Reddel
Choosing between controller options

individual patient decisions
Decisions for individual patients
Use shared decision-making with the patient/parent/carer to discuss the following:
1. Preferred treatment for symptom control and for risk reduction

2. Patient characteristics (phenotype)
Does the patient have any known predictors of risk or response?
(e.g. smoker, history of exacerbations, blood eosinophilia)
3. Patient preference
What are the patients goals and concerns for their asthma?
4. Practical issues
Inhaler technique - can the patient use the device correctly after training?
Adherence: how often is the patient likely to take the medication?
Cost: can the patient afford the medication?
GINA 2016, Box 3-3 (2/2) Provided by H Reddel
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:

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 2016, Box 3-4 (1/2)
Initial controller treatment
Before starting initial controller treatment
Record evidence for diagnosis of asthma, if possible

Record symptom control and risk factors, including lung function
Consider factors affecting choice of treatment for this patient
Ensure that the patient can use the inhaler correctly
Schedule an appointment for a follow-up visit
After starting initial controller treatment

Review response after 2-3 months, or according to clinical urgency
Adjust treatment (including non-pharmacological treatments)
Consider stepping down when asthma has been well-controlled for 3
months
GINA 2016, Box 3-4 (2/2)
Stepwise approach to control asthma symptoms

and reduce risk
UPDATED!
Diagnosis
Patient preference
Symptoms
Exacerbations
Asthma medications
Side-effects
Lung function
STEP 5
STEP 4
PREFERRED
CONTROLLER
CHOICE
STEP 1
STEP 2
e.g.
Low dose ICS

Other
controller
options
Consider low
dose ICS
GINA 2016, Box 3-5 (1/8)
Leukotriene receptor antagonists (LTRA)

Low dose theophylline*
Low dose
ICS/LABA**
Med/high
ICS/LABA
tiotropium,*
omalizumab,
mepolizumab*
Med/high dose ICS Add tiotropium* Add low dose

Low dose ICS+LTRA High dose ICS OCS
+ LTRA
(or + theoph*)
(or + theoph*)
As-needed short-acting beta2-agonist (SABA)
RELIEVER
REMEMBER
TO...
Refer for
add-on
treatment
STEP 3
As-needed SABA or
low dose ICS/formoterol#
Provide guided self-management education (self-monitoring + written action plan + regular review)
Treat modifiable risk factors and comorbidities, e.g. smoking, obesity, anxiety
Advise about non-pharmacological therapies and strategies e.g. physical activity, weight loss, avoidance of
sensitizers where appropriate
Consider stepping up if uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler
technique and adherence first
Consider stepping down if symptoms controlled for 3 months + low risk for exacerbations.
Ceasing ICS is not advised.
Stepwise management - pharmacotherapy

UPDATED!
Diagnosis
Patient preference
Symptoms
Exacerbations
Side-effects
Asthma medications
Lung function
STEP 5
STEP 4
STEP 3
PREFERRED
CONTROLLER
CHOICE
STEP 1
Low dose ICS

Other
controller
options
RELIEVER
Consider low
dose ICS
Refer for
add-on
treatment
STEP 2

GINA 2016, Box 3-5 (2/8) (upper part)
Low dose
ICS/LABA**
Med/high
ICS/LABA
e.g.
tiotropium,*
omalizumab,
mepolizumab*
Med/high dose ICS Add tiotropium* Add low

Low dose ICS+LTRA High dose ICS dose OCS
+ LTRA
(or + theoph*)
(or + theoph*)
As-needed SABA or
*Not for children <12 years

**For children 6-11 years, the
preferred Step 3 treatment is
medium dose ICS
#For
patients prescribed
BDP/formoterol or BUD/
formoterol maintenance and
reliever therapy
Tiotropium by mist inhaler is
an add-on treatment for
patients 12 years with a
history of exacerbations
Stepwise management additional components
REMEMBER
TO...
Provide guided self-management education
Treat modifiable risk factors and comorbidities

Advise about non-pharmacological therapies and strategies
Consider stepping up if uncontrolled symptoms, exacerbations or risks,
but check diagnosis, inhaler technique and adherence first
Consider stepping down if symptoms controlled for 3 months
+ low risk for exacerbations. Ceasing ICS is not advised.
GINA 2016, Box 3-5 (3/8) (lower part)
Step 1 as-needed inhaled short-acting

beta2-agonist (SABA)
STEP 5
STEP 4
PREFERRED
CONTROLLER
CHOICE
STEP 1
STEP 2
Low dose ICS

Other
controller
options
RELIEVER
Consider low
dose ICS

Refer for
add-on
treatment
STEP 3
Low dose
ICS/LABA**
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
Med/high
ICS/LABA
Add tiotropium*
High dose ICS
+ LTRA
(or + theoph*)
Add low
dose OCS
As-needed SABA or

**For children 6-11 years, the preferred Step 3 treatment is medium dose ICS
#For patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy
Tiotropium by mist inhaler is an add-on treatment for patients 12 years with a history of exacerbations
GINA 2016, Box 3-5, Step 1 (4/8)
e.g.
tiotropium,*
omalizumab,
mepolizumab*
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 2016
Step 2 low-dose controller + as-needed

inhaled SABA
STEP 5
STEP 4
PREFERRED
CONTROLLER
CHOICE
STEP 1
STEP 2
Low dose ICS

Other
controller
options
RELIEVER
Consider low
dose ICS

Refer for
add-on
treatment
STEP 3
Low dose
ICS/LABA**
Med/high
ICS/LABA
Med/high dose ICS Add tiotropium*

Low dose ICS+LTRA High dose ICS
(or + theoph*)
+ LTRA
(or + theoph*)
Add low
dose OCS
As-needed SABA or

GINA 2016, Box 3-5, Step 2 (5/8)
e.g.
tiotropium,*
omalizumab,
mepolizumab*
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 2016
Step 3 one or two controllers + as-needed

inhaled reliever
STEP 5
STEP 4
PREFERRED
CONTROLLER
CHOICE
STEP 1
STEP 2
Low dose ICS

Other
controller
options
RELIEVER
Consider low
dose ICS

Refer for
add-on
treatment
STEP 3
Low dose
ICS/LABA**
Med/high
ICS/LABA

+ LTRA
(or + theoph*)
(or + theoph*)
e.g.
tiotropium,*
omalizumab,
mepolizumab*
Add low
dose OCS
As-needed SABA or

GINA 2016, Box 3-5, Step 3 (6/8)
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 FEV1, 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 2016
Step 4 two or more controllers + as-needed

inhaled reliever
STEP 5
STEP 4
PREFERRED
CONTROLLER
CHOICE
STEP 1
STEP 2
Low dose ICS

Other
controller
options
RELIEVER
Consider low
dose ICS

Refer for
add-on
treatment
STEP 3
Low dose
ICS/LABA**
Med/high
ICS/LABA

+ LTRA
(or + theoph*)
(or + theoph*)
e.g.
tiotropium,*
omalizumab,
mepolizumab*
Add low
dose OCS
As-needed SABA or

GINA 2016, Box 3-5, Step 4 (7/8)
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)
Tiotropium by mist inhaler may be used as add-on therapy for
patients aged 12 years with a history of exacerbations
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
GINA 2016
Step 5 higher level care and/or add-on

treatment
UPDATED!
STEP 5
STEP 4
PREFERRED
CONTROLLER
CHOICE
STEP 1
STEP 2
Low dose ICS

Other
controller
options
RELIEVER
Consider low
dose ICS

Refer for
add-on
treatment
STEP 3
Low dose
ICS/LABA**
Med/high
ICS/LABA

+ LTRA
(or + theoph*)
(or + theoph*)
Add low
dose OCS
As-needed SABA or

GINA 2016, Box 3-5, Step 5 (8/8)
e.g.
tiotropium,*
omalizumab,
mepolizumab*
Step 5 higher level care and/or add-on

treatment
UPDATED!
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 tiotropium for patients 12 years with history of exacerbations
Add-on omalizumab (anti-IgE) for patients with severe allergic asthma
Add-on mepolizumab (anti-IL5) for severe eosinophilic asthma (12 yrs)
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
See ERS/ATS Severe Asthma Guidelines (Chung et al, ERJ 2014) for
more detail
GINA 2016
Low, medium and high dose inhaled corticosteroids

Adults and adolescents (12 years)
UPDATED!
Total daily dose (mcg)
Inhaled corticosteroid
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
100
n.a.
200
Fluticasone propionate (DPI or HFA)
100250
>250500
>500
Mometasone furoate
110220
>220440
>440
4001000
>10002000
>2000
Fluticasone furoate (DPI)
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 2016, Box 3-6 (1/2)
Low, medium and high dose inhaled corticosteroids

Children 611 years
Inhaled corticosteroid
Total daily dose (mcg)

Low
Medium
High
Beclometasone dipropionate (CFC)
100200
>200400
>400
Beclometasone dipropionate (HFA)
50100
>100200
>200
Budesonide (DPI)
100200
>200400
>400
Budesonide (nebules)
250500
>5001000
>1000
Ciclesonide (HFA)
80
>80160
>160
Fluticasone furoate (DPI)
n.a.
n.a.
n.a.
Fluticasone propionate (DPI)
100200
>200400
>400
Fluticasone propionate (HFA)
100200
>200500
>500
110
220<440
440
400800
>8001200
>1200
Mometasone furoate
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 2016, Box 3-6 (2/2)
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
GINA 2016
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 (Hagan et al, Allergy 2014)
See GINA 2016 report Box 3-7 for specific step-down options
Stopping ICS is not recommended in adults with asthma because of risk of

exacerbations (Rank et al, JACI 2013)
GINA 2016, Box 3-7
Treating modifiable risk factors
Provide skills and support for guided asthma self-management

This comprises self-monitoring of symptoms and/or PEF, a written
asthma action plan and regular medical review
Prescribe medications or regimen that minimize exacerbations

ICS-containing controller medications reduce risk of exacerbations
For patients with 1 exacerbations in previous year, consider low-dose
ICS/formoterol maintenance and reliever regimen*
Encourage avoidance of tobacco smoke (active or ETS)

Provide smoking cessation advice and resources at every visit
For patients with severe asthma

Refer to a specialist center, if available, for consideration of add-on
medications and/or sputum-guided treatment
For patients with confirmed food allergy:

Appropriate food avoidance
Ensure availability of injectable epinephrine for anaphylaxis
GINA 2016, Box 3-8
Non-pharmacological interventions
Avoidance of tobacco smoke exposure

Provide advice and resources at every visit; advise against exposure of
children to environmental tobacco smoke (house, car)
Physical activity
Encouraged because of its general health benefits. Provide advice about
exercise-induced bronchoconstriction
Occupational asthma
Ask patients with adult-onset asthma about work history. Remove sensitizers
as soon as possible. Refer for expert advice, if available
Avoid medications that may worsen asthma

Always ask about asthma before prescribing NSAIDs or beta-blockers
Remediation of dampness or mold in homes

Reduces asthma symptoms and medication use in adults
(Allergen avoidance)
(Not recommended as a general strategy for asthma)
See GINA Box 3-9 and online Appendix for details
This slide shows examples of interventions with high quality evidence

GINA 2016, Box 3-9
UPDATED!
Indications for considering referral, where

available
Difficulty confirming the diagnosis of asthma

Symptoms suggesting chronic infection, cardiac disease etc
Diagnosis unclear even after a trial of treatment
Features of both asthma and COPD, if in doubt about treatment
Suspected occupational asthma

Refer for confirmatory testing, identification of sensitizing agent,
advice about eliminating exposure, pharmacological treatment
Persistent uncontrolled asthma or frequent exacerbations

Uncontrolled symptoms or ongoing exacerbations or low FEV1
despite correct inhaler technique and good adherence with Step 4
Frequent asthma-related health care visits
Risk factors for asthma-related death

Near-fatal exacerbation in past
Anaphylaxis or confirmed food allergy with asthma
GINA 2016, Box 3-10 (1/2)
Indications for considering referral, where

available
Significant side-effects (or risk of side-effects)

Significant systemic side-effects
Need for oral corticosteroids long-term or as frequent courses
Symptoms suggesting complications or sub-types of asthma

Nasal polyposis and reactions to NSAIDS (may be aspirin
exacerbated respiratory disease)
Chronic sputum production, fleeting shadows on CXR (may be
allergic bronchopulmonary aspergillosis)
Additional reasons for referral in children 6-11 years
Doubts about diagnosis, e.g. symptoms since birth

Symptoms or exacerbations remain uncontrolled
Suspected side-effects of treatment, e.g. growth delay
Asthma with confirmed food allergy
GINA 2016, Box 3-10 (2/2)
ASTHMA FLARE-UPS
(EXACERBATIONS)
2016 GINA Update
Definition and terminology
A flare-up or exacerbation is an acute or sub-acute worsening

of symptoms and lung function compared with the patients
usual status
Terminology
Flare-up is the preferred term for discussion with patients

Exacerbation is a difficult term for patients
Attack has highly variable meanings for patients and clinicians
Episode does not convey clinical urgency
Consider management of worsening asthma as a continuum
GINA 2016
Self-management with a written asthma action plan

Management in primary care
Management in the emergency department and hospital
Follow-up after any exacerbation
Identify patients at risk of asthma-related death
Patients at increased risk of asthma-related death should be

identified
Any history of near-fatal asthma requiring intubation and ventilation

Hospitalization or emergency care for asthma in last 12 months
Not currently using ICS, or poor adherence with ICS
Currently using or recently stopped using OCS
(indicating the severity of recent events)
Over-use of SABAs, especially if more than 1 canister/month

Lack of a written asthma action plan
History of psychiatric disease or psychosocial problems
Confirmed food allergy in a patient with asthma
Flag these patients for more frequent review
GINA 2016, Box 4-1
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 2016
Written asthma action plans
Effective asthma self-management education requires:

If PEF or FEV1
<60% best, or not
improving after
48 hours
Self-monitoring of symptoms and/or lung function

Regular medical review
EARLY OR MILD
GINA 2016, Box 4-2 (1/2)
All patients
Continue reliever
Increase reliever
Continue controller
Early increase in
controller as below
Add prednisolone
4050 mg/day
Review response
Contact doctor
LATE OR SEVERE
Written asthma action plans medication options
Increase inhaled reliever

Increase frequency as needed
Adding spacer for pMDI may be helpful
Early and rapid increase in inhaled controller

Up to maximum ICS of 2000mcg BDP/day or equivalent
Options depend on usual controller medication and type of LABA
See GINA 2016 report Box 4-2 for details
Add oral corticosteroids if needed
Adults: prednisolone 1mg/kg/day up to 50mg, usually 5-7 days

Children: 1-2mg/kg/day up to 40mg, usually 3-5 days
Morning dosing preferred to reduce side-effects
Tapering not needed if taken for less than 2 weeks
GINA 2016, Box 4-2 (2/2)
Managing exacerbations in primary care

PRIMARY CARE
Patient presents with acute or sub-acute asthma exacerbation
Is it asthma?
ASSESS the PATIENT
Risk factors for asthma-related death?

Severity of exacerbation?
MILD or MODERATE
SEVERE
Talks in phrases, prefers

sitting to lying, not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100120 bpm
O2 saturation (on air) 9095%
PEF >50% predicted or best
Talks in words, sits hunched

forwards, agitated
Respiratory rate >30/min
Accessory muscles in use
Pulse rate >120 bpm
O2 saturation (on air) <90%
PEF 50% predicted or best
LIFE-THREATENING
Drowsy, confused
or silent chest
URGENT
START TREATMENT
SABA 410 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour
Prednisolone: adults 1 mg/kg, max.
50 mg, children 12 mg/kg, max. 40 mg
WORSENING
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled
SABA and ipratropium bromide,
O2, systemic corticosteroid
Controlled oxygen (if available): target

saturation 9395% (children: 94-98%)
CONTINUE TREATMENT with SABA as needed

ASSESS RESPONSE AT 1 HOUR (or earlier)
WORSENING
IMPROVING
ASSESS FOR DISCHARGE
ARRANGE at DISCHARGE
Symptoms improved, not needing SABA
Reliever: continue as needed
PEF improving, and >60-80% of personal

best or predicted
Controller: start, or step up. Check inhaler

technique, adherence
Oxygen saturation >94% room air
Prednisolone: continue, usually for 57 days

(3-5 days for children)
Resources at home adequate
Follow up: within 27 days
FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (12 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?
GINA 2016, Box 4-3 (1/7)
PRIMARY CARE
Patient presents with acute or sub-acute asthma exacerbation
Is it asthma?
ASSESS the PATIENT
Risk factors for asthma-related death?

Severity of exacerbation?
MILD or MODERATE
SEVERE
Talks in phrases, prefers

sitting to lying, not agitated
Talks in words, sits hunched

forwards, agitated
Accessory muscles in use
Pulse rate >120 bpm
O2 saturation (on air) <90%
START TREATMENT

GINA 2016, Box 4-3 (4/7)
Drowsy, confused
or silent chest
URGENT
TRANSFER TO ACUTE
CARE FACILITY

LIFE-THREATENING
WORSENING
While waiting: give inhaled SABA

and ipratropium bromide, O2,
systemic corticosteroid
START TREATMENT
TRANSFER TO ACUTE
CARE FACILITY

WORSENING

CONTINUE TREATMENT with SABA as needed

ASSESS RESPONSE AT 1 HOUR (or earlier)
While waiting: give inhaled SABA

and ipratropium bromide, O2,
systemic corticosteroid
WORSENING
IMPROVING
ASSESS FOR DISCHARGE
ARRANGE at DISCHARGE
Symptoms improved, not needing SABA
Reliever: continue as needed
PEF improving, and >60-80% of personal

best or predicted
Controller: start, or step up. Check inhaler technique,

adherence
Oxygen saturation >94% room air
Prednisolone: continue, usually for 57 days

(3-5 days for children)
Resources at home adequate
Follow up: within 27 days
FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (12 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?
GINA 2016, Box 4-3 (7/7)
Managing exacerbations in acute care settings

INITIAL ASSESSMENT
Are any of the following present?
A: airway B: breathing C: circulation
Drowsiness, Confusion, Silent chest
NO
YES
Further TRIAGE BY CLINICAL STATUS

according to worst feature
Consult ICU, start SABA and O2,

and prepare patient for intubation
MILD or MODERATE
SEVERE
Talks in phrases
Prefers sitting to lying
Not agitated
Talks in words
Sits hunched forwards
Agitated
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
Short-acting beta2-agonists
Consider ipratropium bromide
Controlled O2 to maintain
saturation 9395% (children 94-98%)
Oral corticosteroids
Ipratropium bromide
Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
If continuing deterioration, treat as

severe and re-aassess for ICU
ASSESS CLINICAL PROGRESS FREQUENTLY

MEASURE LUNG FUNCTION
in all patients one hour after initial treatment
FEV1 or PEF 60-80% of predicted or

personal best and symptoms improved
MODERATE
Consider for discharge planning
GINA 2016, Box 4-4 (1/4)
FEV1 or PEF <60% of predicted or

personal best,or lack of clinical response
SEVERE
Continue treatment as above
and reassess frequently
INITIAL ASSESSMENT
Are any of the following present?
A: airway B: breathing C: circulation
Drowsiness, Confusion, Silent chest
NO
YES
Further TRIAGE BY CLINICAL STATUS

according to worst feature
Consult ICU, start SABA and O2,

and prepare patient for intubation
MILD or MODERATE
SEVERE
Talks in phrases
Not agitated
Talks in words
Agitated
Pulse rate >120 bpm
GINA 2016, Box 4-4 (2/4)
MILD or MODERATE
SEVERE
Talks in phrases
Not agitated
Talks in words
Agitated
Pulse rate >120 bpm
Ipratropium bromide
GINA 2016, Box 4-4 (3/4)
Ipratropium bromide
If continuing deterioration, treat as

severe and re-assess for ICU
ASSESS CLINICAL PROGRESS FREQUENTLY
MEASURE LUNG FUNCTION
in all patients one hour after initial treatment
FEV1 or PEF 60-80% of predicted or

personal best and symptoms improved
MODERATE
Consider for discharge planning
GINA 2016, Box 4-4 (4/4)
FEV1 or PEF <60% of predicted or

personal best,or lack of clinical response
SEVERE
Continue treatment as above
and reassess frequently
Follow-up after an exacerbation
Follow up all patients regularly after an exacerbation, until

symptoms and lung function return to normal
Patients are at increased risk during recovery from an exacerbation
The opportunity
Exacerbations often represent failures in chronic asthma care,
and they provide opportunities to review the patients asthma
management
At follow-up visit(s), check:
The patients understanding of the cause of the flare-up

Modifiable risk factors, e.g. smoking
Adherence with medications, and understanding of their purpose
Inhaler technique skills
GINA 2016, Box 4-5
END OF PRESENTATION
Thank you for the kind attention!

Bronchial Asthma - REPORT

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Bronchial Asthma - REPORT

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Renato C. Galvan Jr.

Many of the slides in this presentation were taken from the

Global Initiative for Asthma (GINA)

Global Initiative for Asthma

Asthma is one of the most common chronic diseases

GINA Global Strategy for Asthma Management

Not a guideline, but a practical approach to managing asthma

Global Strategy for Asthma Management &

Well-designed RCTs or meta-analyses

Limited number of patients, post hoc or sub-group analyses of

Few RCTs, or small in size, or differing population, or results

Uncontrolled or non-randomized studies

Panel consensus based on clinical experience or knowledge

DIAGNOSIS and DEFINITION

What is known about asthma?

Asthma is a common and potentially serious chronic

Symptoms may be triggered or worsened by factors such as

What is known about asthma?

Asthma can be effectively treated

Avoid troublesome symptoms during the day and night

Asthma is a heterogeneous disease, usually characterized

The diagnosis of asthma should be based on:

Document evidence for the diagnosis in the patients notes,

Asthma is usually characterized by airway inflammation and

Further history and tests for

Alternative diagnosis confirmed?

Confirms asthma diagnosis?

Consider trial of treatment for

Treat for ASTHMA

GINA 2016, Box 1-1 (4/4)

Treat for alternative diagnosis

Diagnosis of asthma symptoms

Increased probability that symptoms are due to asthma if:

Decreased probability that symptoms are due to asthma if:

Diagnosis of asthma variable airflow limitation

Confirm presence of airflow limitation

Confirm variation in lung function is greater than in healthy individuals

GINA 2016, Box 1-2

Typical spirometric tracings

Diagnosis of asthma physical examination

Physical examination in people with asthma

Wheezing is also found in other conditions, for example:

Wheezing may be absent during severe asthma exacerbations

Asthma control - two domains

Check inhaler technique and adherence

GINA 2016, Box 2-1

GINA assessment of symptom control

Any night waking due to asthma?

Reliever needed for symptoms*

Any activity limitation due to asthma? Yes No

This classification is the same as the GINA 2010-12

GINA 2016, Box 2-2A

GINA assessment of symptom control

Any night waking due to asthma?

Reliever needed for symptoms*

Any activity limitation due to asthma? Yes No

B. Risk factors for poor asthma outcomes

Assess risk factors at diagnosis and periodically

Assessment of risk factors for poor asthma

Ever intubated for asthma

Risk factors for fixed airflow limitation include:

Risk factors for medication side-effects include:

The role of lung function in asthma