GINA GUIDELINES 2023 Flashcards
How do we diagnose asthma?
2 defining features of Asthma:
- history of respiratory symptoms such as wheeze, SOB, chest tightness and cough, that vary over time and in intensity AND
- variable expiratory airflow limitation, although airflow limitation may become persistent (no longer available) in long-standing asthma
PE in patients with asthma
often NORMAL but most frequent finding is WHEEZING on auscultation, especially on forced expiration
Criteria for making diagnosis of ASTHMA
- history of variable respiratory symptoms
Typical symptoms are wheeze, SOB, chest tightness, cough:
>People with asthma generally have more than one of these symptoms
>symptoms occur variably over time and vary in intensity
>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 - Evidence of variable expiratory airflow limitation
*Variation in expiratory lung function is greater than in healthy people
>FEV1 increases after inhaling a bronchodilator by >200mL and >12% of the pre-bronchodilator value (or in children, increases from the pre-bronchodilator value by >13% of the predictive value)
>average daily diurnal PEF variability is >10% (in children, >13%)
>FEV1 increases by more than 12% and 200 mL from baseline (in children , by >12% of the predictive value) after 4 weeks of anti-inflammatory treatment
*the greater the variation or the more time excess variation is seen, the more confident you can be of asthma
*testing may need to be repeated during symptoms, in the early morning, or after withholding bronchodilator medications
*at least once during the diagnostic process, eg when FEV1 is low, document that the FEV1/FVC ratio is below the lower limit of normal
*significant bronchodilator responsiveness may be absent during severe exacerbations or viral infections or in long-standing asthma
How to confirm diagnosis of asthma in patients already taking maintenance asthma treatment?
If basis of diagnosis has not already been documented, it should be confirmed with objective testing
If the patient is already taking maintenance asthma treatment and has frequent symptoms, consider a trial of step-up in ICS-containing treatment and repeat lung function testing after 3 months
If the patient has few symptoms, consider stepping down ICS-containing treatment; ensure patient has a written asthma plan, monitor asthma carefully and repeat lung function testing
How to assess patient with asthma?
- ASTHMA CONTROL- assess both symptom control and risk factors
>assess symptom control over the last 4 weeks
>Identify any modifiable risk factors for poor outcomes
>measure lung function before starting treatment, 3-6 months later and then periodically - ASSESS multimorbidity
>comorbids include rhinitis, chronic sinusitis, GERD, obesity, OSA, depression and anxiety
>they may contribute to respiratory symptoms, flare ups and poor QOL. Tx may complicate asthma management - Treatment issues
>record patient’s treatments. Ask about side-effects
>watch the patient using their inhaler to check their technique
>have an open empathic discussion abt adherence
>Check that the patient has a written asthma plan
>Ask the patient about their goals and preferences for asthma treatment
Assessment of symptom control and future risk
Assessment of symptom control
In the past 4 weeks, has the patient had:
*Daytime symptoms more than 2x per week?
*Any night time waking due to asthma?
*SABA reliever needed more than 2x/week?
*Any activity limitation due to asthma?
Level of asthma symptom control
WELL CONTROLLED
In the past 4 weeks, has the patient had:
*Daytime symptoms more than 2x per week?
*Any night time waking due to asthma?
*SABA reliever needed more than 2x/week?
*Any activity limitation due to asthma?
IF NONE OF THE ABOVE –> WELL CONTROLLED
Level of asthma symptom control
PARTLY CONTROLLED
In the past 4 weeks, has the patient had:
*Daytime symptoms more than 2x per week?
*Any night time waking due to asthma?
*SABA reliever needed more than 2x/week?
*Any activity limitation due to asthma?
1-2 OF THE ABOVE –> PARTLY CONTROLLED
Level of asthma symptom control
UNCONTROLLED
In the past 4 weeks, has the patient had:
*Daytime symptoms more than 2x per week?
*Any night time waking due to asthma?
*SABA reliever needed more than 2x/week?
*Any activity limitation due to asthma?
3-4 OF THE ABOVE –> UNCONTROLLED
Risk factors for poor asthma outcomes
- Assess risk factors at diagnosis and periodically, at least every 1-2 years, particularly for patients experiencing exacerbations
- Measure FEV1 at the start of treatment, after 3-6 months for personal best lung function then periodically for ongoing risk assessment
- Having uncontrolled asthma symptoms is an important risk factor for exacerbations
> Meds: SABA overuse, indequate ICS
Comorbids: obesity, chronic rhinosinusitis, GERD, confirmed food allergy, anxiety, depression, pregnancy
exposures: smoking, e-cig, allergen exposure
setting: major socioeconomic problems
lung function:low FEV1, especially if <60% predicted; high bronchodilator responsiveness
Type 2 inflammatory markers: high blood eosinophils, high FeNO despite ICS tx
Others: ever intubated or ICU for asthma; having ≥1 severe exacerbations in the last 12 months
***Having any of these risk factor increases the patient’s risk of exacerbations even if they have few asthma symptoms
Risk factors for developing persistent airflow limitation include:
History: preterm birth, LBW, greater infant weight gain, chronic mucus hypersecretion
Meds: lack of ICS in patients with hx of severe exacerbation
irritant exposures: tobacco smoke, chemicals, occupational or domestic exposures
Investigations: low FEV1, sputum or blood eosinophilia
How to investigate uncontrolled asthma?
- Watch patient using their inhaler. Discuss adherence and barriers to use
- Confirm the diagnosis of asthma
- Remove potential risk factors. Assess and manage comorbidities
- Consider treatment step up
- Refer to a specialist or severe asthma clinic
Asthma management cycle
REVIEW
ASSESS
ADJUST
SABA ONLY treatment is NOT recommended
All patients should receive inhaled ICS either regularly or in patients with mild asthma, as-needed ICS-Formoterol to reduce the risk of serious exacerbations
*For children 6-11yo with mild asthma –> taking ICS whenever SABA is taken is safer than SABA alone
> > > > SABA-only treatment is associated with increased risk of exacerbations and lower lung function, and of asthma-related death;
regular use of SABA increases allergic responses and airway inflammation, and reduces the bronchodilator response to SABA when it is needed
If the patient has troublesome asthma symptoms most days (4-5 days/week) or is waking from asthma once or more a week
Consider starting at STEP 3 (preferrably with maintenance and reliever therapy (MART) with low-dose ICS Formoterol
For most adults and adolescents with asthma, treatment can be started at
STEP 2 with either as-needed low-dose ICS-Formoterol (preferred) or regular daily low-dose ICS plus as-needed SABA or ICS-SABA
**Most patients with asthma do not need higher doses of ICS because at a group level, most of the benefit is obtained at low doses
