Guidelines for asthma management in adults

1. Global Strategy for Asthma Management
2016 Update
www.ginasthma.org

2. 5 Major Domains of Asthma Management
I) Diagnosis and Assessment
II) Symptom Control and Risk Reduction
IV) Management of Exacerbations
III) Patient, Family Education and Self Management
V) Managing Comorbidities and Special Situations

3. I) Diagnosis and Assessment
Diagnosis of Asthma Assessment of Patient
• History of variable respiratory
symptoms.
• Evidence of variable expiratory
airflow limitation:
o Spirometry.
o Peak flow meter.
• Control:
o Symptom control.
o Risk of poor outcome.
• Severity.
• Treatment issues:
o Adherence.
o Inhaler Technique.
• Comorbidities: rhinosinusitis,
COPD, GERD, obesity,
depression, anxiety.

4. • Typical symptoms are wheezes, dyspnoea, cough.
• Symptoms occur variably over time and vary in intensity.
• Symptoms are typically worse in late night and early
morning.
• May be triggered by allergen exposure, infection, exercise,
drugs.
• Cough may be the only symptom (cough variable asthma).
• Documenting variable expiratory airflow limitation is
essential to establish asthma diagnosis, but lack of
variability at time of testing does not exclude asthma.
• This variability should be documented before starting
treatment bec. it usually decreases as lung function
improves. On the other hand, airflow limitation may become
fixed or irreversible over time.

5. • Symptoms may not correlate strongly with degree of
airflow limitation documented by spirometry or PFR.
• Too little symptoms in relation to airflow limitation:
o Elderly with long standing asthma.
o Sedentary person.
Such persons are unable to early recognize failing
control or impending exacerbation, underscoring the
importance of objective measurement of airflow
limitation.
• Too excessive symptoms in relation to airflow limitation:
o Another diagnosis.
o Concomitant respiratory problem.
o Athletes with high baseline lung functions.

6. Spirometry
• It is the recommended method to establish asthma
diagnosis.
• During a forced expiratory maneuver, measure FEV1, FVC
and calculate FEV1/FVC.
• Significant airflow limitation (obstructive pattern of
hypoventilation) is indicated by FEV1/FVC < 0.7
• Significant post BD (bronchodilator) reversibility is
indicated by ↑ FEV1 > 200 mL or > 12% compared with
preBD value.
• Most asthma patients, particularly those on controller
treatment, will NOT exhibit reversibility at each assessment.
• Repeated testing at different visits, or after temporarily
withholding BD medications may be required.

7. Demonstration of Airway Hyperresponsiveness
(Bronchoprovocation Testing)
• Instead of giving a BD, patients suspected to have asthma
who have normal lung function may be subjected to
bronchoprovocation by an airway challenge which may be:
o Direct: inhaled methacholine or histamine.
o Indirect: inhaled mannitol powder or exercise challenge
• Test result is expressed as the provocative concentration
causing 20% fall in FEV1 (PC20).
• False +ve: other causes of airway hyperresponsiveness:
allergic rhinitis, COPD, bronchiectasis, cystic fibrosis.

8. Bronchoprovocation Testing
Patients with asthma sustain FEV1 reduction at a lower stimulus dose and
have an increased maximal bronchoconstrictor response.

9. Peak Flow Meter
• Portable, easy to use by the patient → allowing more
frequent measurement of airflow.
• More effort dependent, less accurate: may underestimate
the degree of airflow limitation.
• Measures obtained are compared with either:
o Predicted Values: obtained from population studies and
stratified by sex, age, height.
o Personal Best: best reading obtained while the patient
is asymptomatic or on full treatment. It is more clinically
relevant because the range of predicted values is wide
and readings differ according to flow meter used.

10. Measures of PEF Variability
• Diurnal Variability
= percent of
(highest – lowest PEF of the day) / average of the 2 readings.
Usually, the lowest PEF is obtained in early morning, before
any treatment, while highest PEF is obtained in the
afternoon or evening.
Average daily diurnal variability over 1 week is calculated.
Variability > 10 % is consistent with asthma.
• Post BD PEF Improvement:
> 60 L/min or > 20% compared to preBD value is consistent
with asthma.

11. ? 30 years male,
175 cm
630 L/min

13. Assessment of Asthma Control
Asthma Control is the extent to which current symptoms
and future risks of asthma have been reduced by treatment.
It has 2 separate domains which should both be included in
control assessment. The patient may have good symptom
control but may still have a high risk for future
exacerbations, eg, due to poor medication adherence and
poor lung function.
Lung function is an important part of assessment of risk of poor
outcome. It should be measured at (or even before) start of treatment,
after 3 – 6 months of treatment and periodically thereafter.
Asthma Severity is assessed retrospectively from the level
of treatment required to control symptoms and prevent
exacerbations. It can be assessed after the patient has been
on control treatment for several months and, if appropriate,
treatment step down has been attempted to find the
patient`s minimum effective level of treatment.

14. Step 1
Step 2
Step 3
Step 4
Step 5
NoYes
NoYes
NoYes
NoYes
Was required treatment provided, symptoms controlled and
exacerbations prevented?
Control Severity
Mild
Moderate
Severe
Treatment
Severity is not static. It may change over months or years

15. • Severe asthma requires step 4 or 5 of treatment to
be controlled, and deteriorates when this treatment
is stepped down, or remains uncontrolled despite
this treatment.
• Severe asthma may reflect intrinsic severity of
asthma itself (refractory asthma) or the effects of
comorbidities, poor adherence and allergen
exposure that interfere with achieving asthma
control (difficult to treat asthma).

16. Assessment of Asthma Control – Symptom control
Simple
Screening
Tools
Numerical
Control
Tools
eg, Asthma Control Test (ACT)

17. Asthma Control Test (ACT)

18. Risk factors for exacerbations
• Poor symptom control.
• High SABA use (with increased mortality if > 1 X 200 dose canister/m).
• Inadequate ICS (not prescribed, poor adherence, incorrect inhaler
technique).
• Low FEV1 (esp if < 60% predicted).
• One or more exacerbations within last year.
• Ever intubated or in ICU for asthma.
• Exposures: smoking, allergen exposure if sensitized.
• Comorbidities: rhinosinusitis, obesity.
• Sputum or blood eosinophilia.
• Major psychological or socioeconomic problem.
• Pregnancy.
Assessment of Asthma Control – Risks of Poor Outcome
Poor outcomes include: - Exacerbations
- Loss of lung function
- Medications side effects

19. Risk factors for loss of lung function (for fixed airflow limitation)
(for airway damage)
• Lack of ICS.
• Exposures: smoking, occupational exposure.
• Low FEV1.
• Sputum or blood eosinophilia.
• Chronic mucus hypersecretion.
Risk factors for medication side effects (corticosteroid SE)
Systemic SE
• Repeated courses of OCS.
• Long term high dose ICS.
• Treatment with P450 inhibitors: macrolide antibiotics, azole antifungals
Local SE
• High dose ICS.
• Poor inhalation technique.

20. Asthma symptoms are not sufficient on their own for
assessment of asthma control:
• Some patients have little symptoms despite major
deterioration of lung functions (sedentary, elderly with long
standing asthma).
• Asthma symptoms may be controlled by inappropriate use
of LABA alone, which leaves the airway inflammation
untreated and increases risks of exacerbations and
mortality.
• Symptoms may be due to other conditions, eg, heart
failure, obesity.
• Anxiety, depression and patient perceptions significantly
contribute to symptom reporting.

21. Assessment of Adherence to Treatment
Poor adherence means failure of treatment to be taken as agreed
upon by the patient and the health care provider.
Approximately 50% of asthmatic patients fail to take medications as
directed, at least part of the time.
Factors Contributing to Poor Adherence
Unintentional
• Difficulty in using inhaler (eg, arthritis).
• Complex drug regimen.
• Misunderstanding.
• Forgetfulness
Intentional
• Not perceiving the need for
treatment.
• Concerns about SE
(real or assumed).
• Denial of diagnosis.
• Cost.

22. Identification of Poor Adherence
• Acknowledge the likelihood of incomplete adherence and encourage
an open non- judgmental discussion about this.
• Check the date of the last controller prescription.
• Check the date and dose counter on the inhaler.
• Monitor dispensing frequency through the MIS (electronic Medical
Information System).
• Drug assay, eg, Prednisolone.
Interventions to Improve Adherence
• Shared decision making for medications, inhaler types and dosage
regimen.
• Simplification of treatment regimen:
o Less medications (eg, ICS + LABA by the same inhaler).
o Less frequent dosing.
• Health education of patients and their families.

23. II) Symptom Control and Risk Reduction
These are the 2 major goals of asthma management.
Symptom control: relief of asthma symptoms as completely
and as fast as possible.
Risk reduction: minimizing future risks of
- Exacerbations.
- Fixed airflow limitation.
- Medications SE.

24. These are the 2 major classes of asthma medications:
Reliever
Fast acting bronchodilator
Its use is intended to relieve
bronchoconstriction during
asthma episodes, leading to
a fast symptomatic
improvement. However, it
has no role in treatment of
the underlying airway
inflammation. Therefore, it
does not influence the
potential for recurrence of
asthma attacks or the
occurrence of
exacerbations.
Controller
Anti-inflammatory or
immune modulating drug
(and bronchodilator as
well), used to treat the
underlying airway
inflammation and thus ↓
the potential for recurrence
of asthma attacks or
occurrence of
exacerbations.

25. Bronchodilators Modulating
Autonomic Control of Airway Reactivity
Beta Agonists
+
Muscarinic
Antagonists
-
LABA
SABA
LAMA
SAMA Relievers
Controllers

26. Recommended Initial Treatment Step
Step Frequency of Asthma Symptoms /
Frequency of SABA Use
Risk Factors for
Exacerbations
1 < Twice a month ---
2 Twice a month – twice a week ---
2 < Twice a month +
3 Twice a month – twice a week +
4 Troublesome asthma symptoms most
days
+
5 Initial presentation with severely
uncontrolled asthma or an asthma
exacerbation
+

27. Following Response and Adjusting Treatment
* Asthma is a variable condition, so treatment adjustments
by the clinician (or occasionally the patient) may be needed.
* Periodic assessment should be done at regular intervals
and should include monitoring the effects of treatment on
patient symptoms and respiratory functions.
* Accordingly, a decision may be made either to continue in
same level of treatment or to step it up or down.
* Any step up or down should be regarded as a therapeutic
trial and the response (in terms of symptom control and
exacerbation frequency) should be reviewed within 2 – 3
months, or earlier if required.

28. Step Up Treatment
3 types:
Sustained Step Up (for at least 2 – 3 months)
It is decided when the current treatment level proves to be
unsatisfactory for symptom control and risk reduction, ie,
escalating treatment is mandatory to get satisfactory control.
The following conditions should be confirmed before a step
up is decided:
• Symptoms are due to asthma, not another problem
(eg, allergic rhinitis).
• Adherence and inhaler technique are satisfactory.
• Modifiable risk factors such as smoking cessation and
allergen avoidance have been adequately addressed.

29. Short Term Step Up (for 1 – 2 weeks)
eg, short term ↑ in ICS dose during episodes of viral
infection or seasonal allergen exposure.
Such a short term step up may be initiated by the patient
according to the written asthma action plan.
Day to Day Adjustment
The frequency of use of the reliever medication (or the
reliever/controller medication in case of use of
ICS/formeterol as both reliever and controller) can be
adjusted by the patient as needed to control his
symptoms (while the maintenance dose of the controller
is continued as usual).

30. Step Down Treatment
• Once asthma control has been achieved and maintained for 3 months
and lung functions have reached a plateau, treatment can often be
stepped down without loss of asthma control.
• Stepping down aims to approach the minimum effective treatment
sufficient to maintain good symptoms control and exacerbation
prevention, in order to minimize costs and the potential for side effects.
• It should be planned in an appropriate time: no respiratory infections,
not travelling, not pregnant.
• Prior to stepping down, the patient should be provided with a written
asthma action plan and instructions for when and how to resume the
previous treatment if symptoms worsen.
• Reduce ICS by 25 – 50% at 2 – 3 months intervals.
• Do not completely withdraw ICS unless this is needed to establish
diagnosis of asthma.
• Monitor closely and book for a follow up visit.

31. Stepwise Management
Step Reliever Controller
1 As needed SABA -------
2 As needed SABA ICS (low dose)
3 As needed SABA ICS/LABA (low dose)
4 As needed SABA ICS/LABA (medium to hig dose)
Leukotriene antagonists
Xanthines
5 As needed SABA
As needed SAMA
Adrenaline
Mg sulphate
Add: LAMA,
Omalizumab, (anti IgE monoclonal Ab)
Mepolizumab (anti IL5 monoclonal Ab)
Use of LABA alone (without ICS) is prohibited as it was found to
increase risk of exacerbations and mortality (Underlying airway
inflammation may be left untreated).

32. – SABAs are the most effective medication for
relieving acute bronchospasm.
– Only selective β2 agonists are recommended.
– SABA administered by the inhaled route provide
as great or greater bronchodilatation with fewer
SE than either the parenteral or oral routes.
– Increasing use of SABA treatment or using
SABA >2 days a week for symptom relief (not
prevention of EIB) indicates inadequate control
of asthma.
– Regularly scheduled, daily, chronic use of SABA
is not recommended.

33. A patient suffers from asthmatic attacks every 2 weeks.
He was prescribed a SABA pMDI (pressurized metered
dose inhaler) to be used as needed. In the follow up
visit, he informed the doctor that asthmatic attacks are
now occurring every 3 – 4 days but are still easily
controlled with the SABA pMDI. The doctor added an
ICS pMDI to be taken twice daily. The patient was
concerned that steroids have many side effects and
once started, he`ll become dependent on them. He
judged that the ICS is not necessary because the SABA
alone was still quite sufficient to relieve the attacks
shortly.
• Comment on severity and control of this case.
• Comment on the patient attitude towards his
treatment.

34. Risk factors for exacerbations
• Poor symptom control.
• High SABA use (with increased mortality if > 1 X 200 dose
canister/m).
• Inadequate ICS (not prescribed, poor adherence, incorrect
inhaler technique).
– ICS’s are the most effective long-term therapy available,
– well tolerated & safe at recommended doses
– The potential but small risk of adverse events from the use of
ICS treatment is well balanced by their efficacy
– Local SE: hoarseness, oral candidiasis.
– Systemic SE: delayed linear growth in children, osteoporosis.
 Patients should rinse their mouths (rinse and spit) after
(ICS) inhalation
 Use the lowest dose of ICS that maintains asthma control:
– Evaluate patient adherence and inhaler technique as well
as environmental factors before increasing the dose of ICS
 Monitor linear growth in children

35. Essential components are:
Skills training to use inhaler devices correctly
Encouraging adherence with medications, appointments
Asthma information
Guided self-management support
 Self-monitoring of symptoms and/or PEF
 Written asthma action plan
 Regular review by a health care provider
GINA 2016
III) Patient, Family Education and Self Management

36. Asthma Action Plan