GINA guidelines Flashcards
2 key defining features of asthma
- history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough
- variable expiratory airflow limitation
evidence of variable expiratory airflow limitation
- FEV1/FVC ratio is below lower limit of normal
- FEV1 increases after inhaling bronchodilator by >200ml and >12% of pre-bronchodilator value; average diurnal PEF variability is >10% in children; FEV1 increases by >12% and 200ml from baseline after 4 weeks of anti-inflammatory treatment
- the greater the variation, the more confident you are that it is asthma
- testing may need to be repeated in the early morning, during symptoms or after withholding bronchodilator medications
- significant bronchodilator reversibility may be absent during severe exacerbations or viral infections
characterised by cough and airway hyperresponsiveness, and documenting variability in lung function is essential to make the diagnosis
Cough variant asthma
How to assess a patient with asthma:
Asthma control
Assess both symptom control and risk factors
- assess symptom control over the last 4 weeks
- Identify modifiable risk factors for poor outcomes
- measure lung function before starting treatment, 3-6 months later and then periodically
How to assess a patient with asthma:
Are there any comorbidities?
rhinitis, chronic rhinosinusitis, GERD, obesity, OSA, depression and anxiety
How to assess a patient with asthma:
Treatment issues
ask about side effects
watch the patient using inhaler to check their technique
empathic discussion about adherence
check if there is an action plan
ask about the goals and preferences for asthma treatment
What are the symptoms to be asked to asthma patients?
In the past 4 weeks, has the patient had:
- daytime symptoms more than 2x a week?
- any night waking due to asthma?
- SABA reliever needed more than 2x a week?
- Any activity limitation due to asthma?
In the past 4 weeks, has the patient had:
- daytime symptoms more than 2x a week?
- any night waking due to asthma?
- SABA reliever needed more than 2x a week?
- Any activity limitation due to asthma?
none of the above symptoms is called
well controlled
In the past 4 weeks, has the patient had:
- daytime symptoms more than 2x a week?
- any night waking due to asthma?
- SABA reliever needed more than 2x a week?
- Any activity limitation due to asthma?
patient has 1-2 of the above symptoms
partly controlled
In the past 4 weeks, has the patient had:
- daytime symptoms more than 2x a week?
- any night waking due to asthma?
- SABA reliever needed more than 2x a week?
- Any activity limitation due to asthma?
Patient has 3-4 of the above symptoms
Uncontrolled
When should we measure FEV1 in patients with asthma?
start of treatment
after 3-6 months for personal best lung function
periodically or ongoing risk assessment
asthma that can be controlled by with reliever alone or low dose ICS
Mild asthma
asthma that requires high-dose ICS-LABA
severe asthma
long term goals of asthma management
risk reduction and symptom control
GINA now recommends that every adult and adolescent should receive
ICS-containing controller medication to reduce risk of serious exacerbations even in patients with infrequent symptoms
SABA only treatment is associated with
increased risk of exacerbations and lower lung function
Regular use of SABA increases allergic responses and airway inflammation and reduces bronchodilator response to SABA when needed
patient has troublesome asthma symptoms on most days; waking asthma >/= to once/week
start at step 3 (maintenance and reliever therapy with low dose ICS-Formoterol)
patient presents with severely uncontrolled asthma at presentation or initial presentation is during exacerbation
start regular controller treatment at step 4
medium dose ICS-Formoterol maintenance and reliever therapy
consider stepping down if asthma symptoms are controlled for
3 months
However, in adults and adolescents, ICS should not be completely stopped
preferred approach recommended by GINA to adults and adolescents
TRACK 1 (reliever is as needed low dose ICS-Formoterol)
- When a patient at any treatment step has asthma symptoms, they use low-dose ICS-Formoterol in a single inhaler for symptom relief
- In steps 3-5, patients also take ICS-Formoterol as regular daily treatment. this is called Maintenance and reliever therapy
what is track 2 in asthma management in adults and adolescents
alternative when track 1 is not possible or not preferred by by a patient who has no exacerbations on their current therapy
- In step 1, patient takes a SABA and low dose ICS together for symptom relief when symptoms occur, either in combination inhaler or with ICS taken right after SABA
- In steps 2-5, SABA alone is used for symptom relief and the patient takes ICS-containing controller medication regularly every day
GINA guidelines on asthma treatment for 12 years old and above
RELIEVER: as needed low dose ICS-Formoterol
CONTROLLER:
Steps 1-2: as needed low dose ICS-Formoterol
Step 3: low dose maintenance ICS-Formoterol
Step 4: medium dose maintenance ICS-Formoterol
Step 5: refer
GINA guidelines on asthma treatment for 12 years old and above controller and alternative reliever
ALTERNATIVE RELIEVER: as needed short acting B2 agonist
CONTROLLER:
Step 1: takeICS whenever SABA taken
Step 2: low dose maintenance ICS
Step 3: low dose maintenance ICS-LABA
Step 4: medium/high dose maintenance ICS-LABA
Step 5: add on LAMA; refer for phenotypic assessment
Child with asthma 12yrs old and above with symptoms less than 4-5 days a week
Steps 1-2: as needed low dose ICS-Formoterol
Child with asthma 12 years old and above with symptoms on most days or waking with asthma once a week or more
Step 3: low dose maintenance ICS-Formoterol
Child 12 years old and above with daily symptoms of asthma or waking with asthma once a week or more, and low lung function
Step 4: medium dose maintenance ICS-Formoterol
Children 6-11 years with asthma:
Preferred controller to prevent exacerbations and control symptoms
RELIEVER: as needed SABA
PREFERRED CONTROLLER:
Step 1: low dose ICS taken whenever SABA taken
Step 2: daily low dose inhaled corticosteroids (ICS)
Step 3: Low dose ICS-LABA or medium dose ICS or very low dose ICS-Formoterol maintenance and reliever (MART)
Step 4: medium dose ICS-LABA or low dose ICS-Formoterol maintenance and reliever (MART); refer for expert advise
Step 5: refer for phenotypic assessment
In children 6-11 years: symptoms less than 2x a month
Step 1: low dose ICS taken whenever SABA taken
In children 6-11 years: symptoms 2x a month or more but less than daily
Step 2: daily low dose inhaled corticosteroids (ICS)
In children 6-11 years:
symptoms most days or waking with asthma once a week or more
Step 3: Low dose ICS-LABA or medium dose ICS or very low dose ICS-Formoterol maintenance and reliever (MART)
In children 6-11 years:
symptoms most days or waking with asthma once a week or more and low lung function
Step 4: medium dose ICS-LABA or low dose ICS-Formoterol maintenance and reliever (MART); refer for expert advise
Adults and adolescents ICS
BDP 200-500mcg Budesonide 200-400mcg Ciclesonide 80-160mcg Fluticasone furoate 100mcg Fluticasone proprionate Mometasone furoate
usual dose of as needed Budesonide-Formoterol is one inhalation of
200.6mcg taken whenever needed for symptom relief
maximum recommended dose of Budesonide-Formoterol in a day
total of 72mcg Formoterol
in mild asthma, average usage is 3-4 inhalations per week
taken as needed and before exercise showed similar benefit as daily ICS
ICS-Formoterol
*suggests that patients prescribed with as needed ICS-Formoterol do not need to be prescribed a SABA for pre-exercise use
maximum recommended dose of ICS-Formoterol in a single day is total of
48mcg formoterol for BDP-Formoterol (36mcg delivered dose)
72mcg formoterol for budesonide-Formoterol (54mcg delivered dose)
non-pharmacological strategies and interventions
smoking cessation
physical activity: encourage to engage in regular physical activity because of general benefits
investigation for occupational asthma
identify aspirin-exacerbated respiratory disease
In patients with asthma who will undergo surgery, when should we give intra-operative Hydrocortisone to reduce risk of adrenal crisis?
patients on long term high dose ICS or having more than 2 weeks’ OCS in the past 6 months
written asthma action plan should incude:
patient’s usual asthma medications
when and how to increase medications and start OCS
how to access medical care if symptoms failed to respond
management of patients with signs of severe exacerbation, confused, has silent chest
immediately give inhaled SABA, inhaled Ipratropium bromide, oxygen and systemic corticosteroids
talks in phrases, prefers sitting to lying, not agitated; RR increased, accessory muscles not used, PR 100-120bpm, 90-95% O2 sat, PEF >50%
mild or moderate asthma
talks in words, sits hunched forward, agitated; RR >30/min, accessory muscles in use, PR >120, O2 sat <90%, PEF <50%
severe asthma
management of mild to moderate asthma
SABA 4-10 puffs by pMDI + spacer repeat every 20 mins for 1 hour
Prednisolone: adults 40-50mg, children 1-2mg/kg, max 40mg
controlled oxygen (if available): target saturation 93-95% (children 94-98%)
assess response at 1 hour or earlier
these patients with mild to moderate exacerbations can be discharged
symptoms improved; not needing SABA
PEF improving and >60-80% of personal best or predicted
O2 sat >94% at room air
resources at home adequate
