Asthma GINA

1. Asthma Management-GINA
Dr.Hamisi Mkindi

2. Asthma
• What is it?
• Pathogenesis and types + Drug targets in pathogenesis
• Clinical Manifestation
• Physical exam
• Diagnostic study,Ddx
• Management-GINA
• Exarcebations

3. TAKING HX
⚫ Since when it start & previous attack?
Eg.since 4 years old, once in 2 months, last attack was on October
Day time Sx/week,nocturnal awakening/month,Use of SABA to releive
symptoms,intereference with normal activities between
exarcebations,exarcebation/year.
⚫ Aggravating and relieving factors?
Eg.cold drinks, cold weather or do vigorous exercise
⚫ Have any prolong URTI sx?
⚫ Prev hospital administration?
Eg.No hospital administration before this.
⚫ History of atopy? – Eg.No eczema or has rhinitis etc
⚫ Family history of asthma? -Eg.Strong family hx of asthma

4. PHYSICAL EXAM
⚫ OBSERVATION
• -(tachypnic, wheezing, drowsiness, central cyanosis, hyperinflated chest, peripheral
cyanosis, using accessory muscle when breathing)
⚫ PALPATION
• - Decrease symetrically chest wall expansion
⚫ PERCUSSION
• -resonance
⚫ AUSCULTATION
• -(reduced breath sound, rhonci, vesicular breath sound with
• prolong expiration time)

5. ADVANCED LAB / IMMUNOLOGICAL TESTING
• For patients with severe persistent asthma, a CBC and differential (to evaluate
the presence/absence of eosinophils and exclude anemia as a cause of
dyspnea) and a total serum immunoglobulin E (IgE) level (eg, for allergic
bronchopulmonary aspergillosis [ABPA] or for identification of candidates for
anti-IgE therapy) are usually obtained.
• Specific testing for aspergillus sensitization (skin test or immunoassay) and an
antineutrophil cytoplasmic antibody (ANCA) are performed in those with high
blood eosinophils to evaluate for ABPA and eosinophilic granulomatosis with
polyangiitis (EGPA, Churg-Strauss), respectively

6. UPON DIAGNOSIS OF ASTHMA IN THE
ABOVE PATIENT, WHAT WOULD BE THE
FIRST CHOICE OF TREATMENT?
HOW TO DECIDE THE BEST INHALER?
‘Releivers Vs Controllers’

7. Management principles
• Education and avoidance of environmental triggers
• Use quick-relief rescue medication as needed for all Pts
• Goal to achieve complete control = daily sx ≤2/wk, ∅ nocturnal sx
or limitation of activity, reliever med ≤2/wk, nl peak expiratory
flow rate or FEV1; partly controlled = 1–2 of the above present in a
wk; uncontrolled = ≥3 of the above present in a wk
• Step up treatment as needed to gain control, step down as
tolerated

9. Low dose ICS whenever
SABA taken, or daily LTRA,
or add HDM SLIT
Medium dose ICS, or
add LTRA, or add
HDM SLIT
Add LAMA or LTRA or
HDM SLIT, or switch to
high dose ICS
RELIEVER:As-needed short-acting beta2-agonist
STEP 1
Take ICS 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 assessment
of phenotype. Consider
high dose maintenance
ICS-LABA, ± anti-IgE,
anti-IL5/5R, anti-IL4R,
anti-TSLP
RELIEVER:As-needed low-dose ICS-formoterol
STEPS 1 – 2
As-needed low dose ICS-formoterol
STEP 3
Low dose
maintenance
ICS-formoterol
STEP 4
Medium dose
maintenance
ICS-formoterol
Refer for assessment
of phenotype. Consider
high dose maintenance
ICS-formoterol,
± anti-IgE, anti-IL5/5R,
anti-IL4R, anti-TSLP
Treatment of modifiable risk factors
and comorbidities
Non-pharmacological strategies
Asthma medications (adjust down/up/between tracks)
Education & skills training
STEP 5
Add-on LAMA
Adults & adolescents
12+ years
Personalized asthma management
Assess,Adjust, Review
for individual patient needs
Symptoms
Exacerbations
Side-effects
Lung function
Patient satisfaction
Confirmation of diagnosis if necessary
Symptom control & modifiable
risk factors (see Box 2-2B)
Comorbidities
Inhaler technique & adherence
Patient preferences and goals
CONTROLLER and
PREFERRED RELIEVER
(Track 1). Using ICS-formoterol
as reliever reduces the risk of
exacerbations compared with
using a SABA reliever
Other controller options for either
track (limited indications, or less
evidence for efficacy or safety)
CONTROLLER and
ALTERNATIVE RELIEVER
(Track 2). Before considering a
regimen with SABA reliever,
check if the patient is likely to be
adherent with daily controller
See GINA
severe
asthma guide
Add azithromycin (adults) or
LTRA. As last resort consider
adding low dose OCS but
consider side-effects
© Global Initiative for Asthma, www.ginasthma.org
GINA 2022, Box 3-5A

11. Comorbidities
• Rhinitis, Sinusitis / nasal polyps
• Obesity
• Gastro-esophageal reflux disease
• Anxiety & depression
• FoodAllergy
• Obstructive sleep apnea
• Asthma-COPD overlap

12. HOW CAN WE PREDICT FUTURE
RISK OF EXACERBATIONS?

13. WHY IS IT IMPORTANT TO PREVENT
EXACERBATIONS?
1. Cost to patient and healthcare system
2. To prevent Lung function decline
3. Improve quality of life
4. All of above