GINA at a Glance Asthma

8/18/2019 GINA at a Glance Asthma

1/8

Revised 2009

B

GINA

At-A-Glance AsthmaManagement Reference

GINA

At-A-Glance AsthmaManagement Reference

GINA 2009 463%' %6'54 #3' #5 www.gnathma.org.

© 2010 Medical Communications Resources, Inc.


2/8

DIAGNOSING ASTHMAAsthma can often be diagnosed on the basis of a patient’s 454 and'+%# *+453 (e.g., see below).

Measurements of 6 6%5+ provide an assessment of the severity,reversibility, and variability of airflow limitation, and help confirm thediagnosis of asthma.

S+3'53 is the preferred method of measuring airflow limitation and itsreversibility to establish a diagnosis of asthma.

• An increase in FEV1 of 12% and 200 ml after administration of abronchodilator indicates reversible airflow limitation consistent withasthma. (However, most asthma patients will not exhibit reversibility ateach assessment, and repeated testing is advised.)

P'# '+3#53 8 (PEF) measurements can be an important aid in bothdiagnosis and monitoring of asthma.

• PEF measurements are ideally compared to the patient’s own previous

best measurements using his/her own peak flow meter.• An improvement of 60 L/min (or 20% of the pre-bronchodilator PEF)

after inhalation of a bronchodilator, or diurnal variation in PEF of morethan 20% (with twice-daily readings, more than 10%), suggests adiagnosis of asthma.

A+5+# +#45+% 5'454:

• For patients with symptoms consistent with asthma, but normal lung

function, measurements of #+38# 3'44+7''44 to methacholine,histamine, direct airway challenges such as inhaled mannitol, or exercisechallenge may help establish a diagnosis of asthma.

• S+ 5'454 8+5* #'3'4 3 '#463''5 4'%++% IE + 4'36:The presence of allergies increases the probability of a diagnosis of asthma, and can help to identify risk factors that cause asthma symptomsin individual patients.

Q6'45+0/4 50 C0/4+&'3 +/ 5*' D+#)/04+4 0( A45*.#

• Has the patient had an attack or recurrent attacks of wheezing?• Does the patient have a troublesome cough at night?• Does the patient wheeze or cough after exercise?• Does the patient experience wheezeing, chest tightness, or cough af ter exposure

to airborne allergens or pollutants?• Do the patient's colds “go to the chest” or take more than 10 da ys to clear up?

• Are symptoms improved by appropriate asthma treatment?


3/8

ASTHMA CONTROLThe goal of asthma care is to achieve and maintain control of theclinical manifestations of the disease for prolonged periods. When

asthma is controlled, patients can prevent most attacks, avoidtroublesome symptoms day and night, and keep physically active.

The assessment of asthma control should include control of the clinicalmanifestations and control of the expected future risk to the patient suchas exacerbations, accelerated decline in lung function, and side-effectsof treatment. In general, the achievement of good clinical control of asthma leads to reduced risk of exacerbations.

Examples of validated measures for assessing clinical control of asthmainclude:• Asthma Control Test (ACT): www.asthmacontrol.com• Childhood Asthma Control test (C-Act)

• Asthma Control Questionnaire (ACQ):www.qoltech.co.uk/Asthma1.htm

• Asthma Therapy Assessment Questionnaire (ATAQ):www.ataqinstrument.com

• Asthma Control Scoring System

Levels of Asthma Control

C*#3#%5'3+45+% C53'( l l o f t h e fo l l ow ing )

P#35 C53'( ny m easure presen t in any week )

U%53'

D#5+' 454 None (twice or less/week) More than twice/week h ree or more

features of

part ly control led

as thm a presen t

in any w eek *†

L++5#5+4 #%5+7+5+'4 None Any

N0%63#- 4:.10.4/#8#,'+)

None Any

N'' 3 3'+'7'3/3'4%6' 53'#5'5

None (twice or less/week) More than twice/week

L6 6%5+(PEF 3 FE 1)

;Normal < 80% predicted or

personal best (if known)

B. A44'44'5 F6563' R+4 (risk of exacerbations, instability, rapid decline in lung function, side-effects)

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.

* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate.

† By definition, an exacerbation in any week makes that an uncontrolled asthma week.

‡ Lung function testing is not reliable for children 5 years and younger.


4/8

E44'5+# F'#563'4 5*' D%53-P#5+'5 P#35'34*+ 5 A%*+'7' G6+' S'-M##''5 + A45*#

• Education• Joint setting of goals• Self-monitoring. The person with asthma is taught to combine assessment of asthma control with

educated interpretation of key symptoms• Regular review of asthma control, treatment, and skills by a health care professional• Written action plan. The person with asthma is taught which medications to use regularly and which

to use as needed, and how to adjust treatment in response to worsening asthma control• Self-monitoring is integrated with written guidelines for both the long-term treatment of asthma and

the treatment of asthma exacerbations.

E6%#5+ # 5*' P#5+'5/D%53 P#35'34*+

G#: To provide the person with asthma, their family, and other caregivers with suitable informationand training so that they can keep well and adjust treatment according to a medication plan developedwith the health care professional.

K' %'54:

q Focus on the development of the partnershipq Acceptance that this is a continuing processq A sharing of informationq Full discussion of expectationsq Expression of fears and concerns

P37+' 4'%++% +3#5+, 53#++, # #7+%' #$65:

q Diagnosisq Difference between “relievers” and “controllers”q Use of inhaler devicesq Prevention of symptoms and attacksq Signs that suggest asthma is worsening and actions to takeq Monitoring control of asthmaq How and when to seek medical attention

T*' '34 5*' 3'6+3'4:

q A guided self-management planq

Regular supervision, revision, reward, and reinforcement

F#%534 I77' + N-A*'3'%'

N-36 #%534Misunderstanding or lack of instructionFears about side effectsDissatisfaction with health care professionalsUnexpressed/undiscussed fears or concerns

Inappropriate expectationsPoor supervision, training, or follow-upAnger about condition or its treatmentUnderestimation of severityCultural issuesStigmatizationForgetfulness or complacencyAttitudes toward ill healthReligious issues

D36 #%534

Difficulties with inhaler devicesAwkward regimes (e.g., four timesdaily or multiple drugs)Side effects

Cost of medicationDislike of medicationDistant pharmacies

DOCTOR-PATIENT PARTNERSHIP


5/8

Man agementA ppr oach B asedOn Contr olForC hildr enOlde r Than5 Year s,A dolescentsa ndAdults

Contr oller optio ns***

*ICS=inhale dglucocor ticoster oid s**=Receptor a ntagonistor synthe sisinhibitor s***=Pr ef er r e dcontr oller options a r eshowninshaded boxes

Tr eatmentS teps Asneede dr apid-actingβ2 -agonistA sneeded r apid-actingβ2-agon ist

Low-doseICS pluslong-actingβ2-a gonistSelectoneLeukotr ienemodif ier **SelectoneMedium-or high-doseIC SMedium-o r high-doseICSplus long-actingβ2-a gonist

Low-doseICS plusleukotr ienemo dif ier Low-doseICS plussustainedr ele asetheophylline

ToStep 3tr eatment,selecto neor mor e ToStep4tr eatment,addeither Asthmaeducatio nEnvir onmentalcon tr ol

L ow-doseinhaledICS*O ra lglucocor ticoster o id(lowestdose) Anti-IgEtr eatment

Leu kotr ienemodif ier Sustain edr eleasetheo phylline

C ontr olled Maintainandf ind lowestcontr ollings tepPar tl ycontr olled C onsider stepp inguptogaincontro lUn contr olled S tepup untilcontr olledEx acer bation T r eata sexacer bation

Tr eatment ActionLeve lof Contr ol R e d u c e

Reduce I nc r ease I n c r e a s e

2Step1Step 3 Step 4Ste p 5Step

Management Approach Based On ControlFor Children Older Than 5 Years, Adolescents and Adults

Controller

options***

* ICS = inhaled glucocorticosteroids

**= Receptor antagonist or synthesis inhibitors

*** = Preferred controller options are shown in shaded boxes

Treatment Steps

As needed rapid-acting β2-agonist

As needed rapid-acting β2-agonist

Low-dose ICS plus

long-acting β2-agonist

Select one

Leukotriene

modifier**

Select one

Medium-or

high-dose ICS

Medium-or high-dose

ICS plus long-acting

β2-agonist

Low-dose ICS plus

leukotriene modifier

Low-dose ICS plussustained release

theophylline

To Step 3 treatment,select one or more

To Step 4 treatment,add either

Asthma education

Environmental control

Low-dose inhaled

ICS*Oral glucocorticosteroid

(lowest dose)

Anti-IgE

treatment

Leukotriene

modifier

Sustained release

theophylline

Controlled Maintain and find lowest controlling step

Partly controlled Consider stepping up to gain control

Uncontrolled Step up until controlled

Exacerbation Treat as exacerbation

Treatment ActionLevel of Control

R e d u c e

Reduce Increase

I n c r e a s e

2Step1Step 3Step 4Step 5Step

For guidelines on management of asthma in children 5 years and younger, please refer to the

G-0$#- S3#'): (03 *' D+#)04+4 #& M##)'.' 0( A4*.# + C*+-&3' 5 !'#34 #& !06)'3 ,

available at www.ginasthma.org.

Alternative reliever treatments include inhaled anticholinergics, short-acting oral 2 -agonists, some

long-acting 2-agonists, and short-acting theophylline. Regular dosing with short and long-acting2-agonist is not advised unless accompanied by regular use of an inhaled glucocorticosteroid.

MANAGEMENT APPROACHBASED ON CONTROL


6/8

P#3#'5'3 1

Breathless

Talks in

Alertness

Respiratory rate

Accessorymuscles andsuprasternal

retractionsWheeze

Pulse/min.

PEFafter initialbronchodilator% predicted or% personal best

PaO2 (on air)*and/or

PaCO2*

SaO2% (on air)*

Mild

Walking

Sentences

May be agitated

Increased

Usually not

Moderate, oftenonly endexpiratory

< 100

Over 80%

Normal Testnot usually

necessary< 45 mmHg

> 95%

M'3#5'

TalkingInfant - softer,shorter cry;difficulty feeding

Phrases

Usually agitated

Increased

Usually

Loud

100-120

Approximately60-80%

> 60 mmHg

< 45 mmHg

91-95%

S'7'3'

At restInfant stopsfeeding

Words

Usually agitated

Often > 30/min

Usually

Usually Loud

> 120

< 60% predictedor personal best(100 L/minadults) orresponse lasts< 2 hours

< 60 mmHg

Possible cyanosis> 45 mmHg:Possiblerespiratoryfailure

< 90%

R'41+3#03: #33'4 +..+'

Drowsy orconfused

Paradoxical

Paradoxical

thoraco-abdominal

movement

Absence of wheeze

Bradycardia

Hypercapnia (hypoventilation) develops more readily in young children than in adults and adolescents.

Guide to rates of breathing associated with respiratory distress in awake children

Age Normal rate < 2 months < 60/min2-12 months < 50/min

1-5 years < 40/min6-8 years < 30/min

Guide to limits of normal pulse rate in children:

Infants 2-12 months -Normal rate


7/8

Management of Asthma Exacerbations in Acute Care Setting

Reassess after 1-2 Hours

Improved (see opposite)

Initial Assessment (see Figure 4.4-1) H?, ?' '' (';;', ; '? ;, ' ',

'? ', "EF FE&1, ? ';', '' ' ' )

Reassess after 1 Hour"?' E'', "EF, !2 ';' ' '

Initial Treatment !? ' !2 ';' D 90% (95% ) I' '-' 2-' ;;? ;.

$? ; ' , ' ? ';, .

$' '' ' ' ''.

Criteria for Moderate Episode: "EF 60-80% /' "?' ': ' ?,

'? ; ;

Treatment: !? I' 2-' ' ' '

? 60 !' ; C; ' 1-3 ;,

Good Response within1-2 Hours: # ;' 60

' ' ' "?' ' ':

"EF > 70% !2 ';' > 90%

(95% )

Incomplete Response within 1-2 Hours: # ' ' ''

'' "?' ':

' "EF < 60% !2 ';'

Admit to Acute Care Setting !? I' 2-'

' $? ; I'; ';

M "EF, !2 ';',;

Poor Response (see above):

A I C'Incomplete response in 6-12hours (see above) C ' I

C' =6-12 ;

Improved: Criteria for Discharge Home

"EF > 60% /' $;' '/' '

Home Treatment: C; ' 2-' C549/+8, /4 359: )'9+9, 58'2 2;)5)58:/)59:+85/9 C ' ' ' ' "' ;': ' ?

#= ' 'C ' =-;

Criteria for Severe Episode: H? ' ' '' '' "EF < 60% /' "?' ': ? ' ,

' ' ' 'Treatment: !? I' 2-' ' ' ' $? ; I'; ';

t

t t

t

t

t

t

Poor Response within1-2 Hours: # ' ' ''

'' "?' ': ?

, =,;

"EF < 30% "C!2 > 45 H " !2 < 60 H

Admit to Intensive Care !? I' 2-' +

' I4:8'


8/8

T*' G$# I+5+#5+7' 3 A45*# +4 4635' $ '6%#5+# 3#54 3: A453#"''%#, B'*3+'3 I'*'+,C*+'4+ G36, C+#, G#S+5*K+', M'# P*#3#, M'3% S*#3 & D*', M+5646$+4*+ T##$', N7#35+4,N%', # P*#3A+4.

r in t i n g a n d d is t r i b u t i o n h a s b e e n m a d e p o s s ib l e b y a n e d u c a t io n a l g r a n t .

Estimated Equipotent Daily Doses of Inhaled Glucocorticosteroids for Adults†

B' ' 200 - 500 >500 - 1000 >1000 - 2000

B;* 200 - 400 >400 - 800 >800 - 1600

C* 80 - 160 >160 - 320 >320 - 1280

F; 500 - 1000 >1000 - 2000 >2000

F;' 100 - 250 >250 - 500 >500 - 1000

M' ;'* 200 - 400 >400 - 800 >800 - 1200

' ' 400 - 1000 >1000 - 2000 >2000

@ C536'8/9549 ('9+ ;654 +/)')? ':'.E "':/+4:9 )549/+8+ 58 / '/2? 59+9 +>)+6: 58 958: 6+8/59 95;2 (+ 8++88+ :5 ' 96+)/'2/9: 58 '99+993+4: :5 )549/+8'2:+84'://3;3 8+)533+4+ 59+9 '8+ '8(/:8'8? (;: =/: 685254+ ;9+ '8+ '995)/':+ =/:/4)8+'9+ 8/91 5 9?9:+3/) 9/+ ++):9.

* A6685400

C* 80 - 160 >160 - 320 >320

F; 500 - 750 >750 - 1250 >1250

F;' 100 - 200 >200 - 500 >500M' ;'* 100 - 200 >200 - 400 >400

' ' 400 - 800 >800 - 1200 >1200

@ C536'8/9549 ('9+ ;654 +/)')? ':'.

E "':/+4:9 )549/+8+ 58 / '/2? 59+9 +>)+6: 58 958: 6+8/59 95;2 (+ 8++88+ :5 ' 96+)/'2/9: 58 '99+993+4: :5 )549/+8'2:+84'://3;3 8+)533+4+ 59+9 '8+ '8(/:8'8? (;: =/: 685254+ ;9+ '8+ '995)/':+ =/:/4)8+'9+ 8/91 5 9?9:+3/) 9/+ ++):9.

* A6685

GINA at a Glance Asthma

Documents

Transcript of GINA at a Glance Asthma