General Review of GINA guidelines about asthma management.

1. Dr Gabriel Guevara Conrado.
Asthma
GINA Guideline Summary

2. Asthma causes respiratory symptoms such as wheezing, shortness of breath,
chest tightness and cough that vary very time, including its frequency and
intensity. This symptoms are associated to variable expiratory air
fl
ow limitations.
Definition
GINA 2023

3. Suspecting Asthma
• In the past 12 months, have you?
• Had sudden severe episode or recurrent episodes of coughing, wheezing,
chest tightness or shortness of breath?
• Had colds that “go to the chest” or take more than 10 days to get over?
• Had coughing, wheezing or shortness of breath during a season of year?
• Has Coughing, wheezing, SOB in certain places or triggers?
• Used any medications that help you breathe better? How often?
• Had symptoms relived when the medications are used?
• In the past four weeks have you had coughing, wheezing or SOB that:
• At night has awakened you
• Upon awakening
• After running, moderate exercise or other physical activity
Reproduced from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of
Asthma. NIH Publication no. 08-4051, 2007.

4. Diagnosis
• Diagnosis is based on Two Pilars
• History of symptoms and variability in time and intensity
• Evidence of variable expiratory air
fl
ow limitation

5. 1. History of variable respiratory symptoms
Chest tightness, SOB, Cough, Wheezing
A. Patients with asthma generally have more than one of the symptoms
B. Symptoms are worse at night or upon waking
C. Variability in time and intensity
D. Symptoms associated to triggers
E. Symptoms are worse during respiratory viral infections

6. 2. Evidence of variable expiratory airflow limitation
Spirometry or PEF
A. FEV1 post bronchodilator with an improvement of >12% or more than 200ml
en adults or >12% in children
B. PEF daily diurnal with variability of >10% in adults or >13% in children
C. Asthma ICS trial with improvement of FEV1 >12% in adults and children after
4 weeks with Asthma treatment

7. Spirometry

8. Special Considerations
• Spirometry with an improvement of volumes after bronchodilator
strongly supports diagnosis of asthma. But income cases
Spirometry will be normal or during crises may not improve; in these
cases a trial of asthma medication might be indicated.
• Improvement on medication is su
ffi
cient to make diagnosis on this
patients.
• If trial of asthma fails then Bronchoprovocaion with Methacholine,
cold air or exercise may be warranted.

9. Diagnosis
• Intermittent or chronic symptoms + Wheezing (with symptoms and absent
when symptoms resolve) - Strongly suggestive of asthma.
• Con
fi
rmation is based on 3 key elements:
• Demonstration of variable air
fl
ow limitation, Pref. Spirometry.
• Documentation of reversible obstruction
• Exclusion of alternative diagnosis
• Bronchiolitis, Laryngotrachobronchitis, Foreign body, tumours, vascular
compression ring, bronchopulmonary dysplasia, GERD, etc.

10. Px with Respiratory
Symptoms
Detailed history and examination
suggestive of asthma
Is patient already using ICS
treatment?
No
Begin treatment for asthma
Spirometry with reversible test/
results support Asthma
Clinically Urgent
Initiate empiric
treatment and
reassess in 1 to 3
months
YES
Repeat reversibility
test during symptoms
or withhold
Bronchodilators

11. Starting Asthma treatment
Initial recommendations
• NEVER use SABA (Short acting beta agonist, eg. Salbutamol) as
monotherapy, it must always be accompanied by ICS.
• In patients with mild asthma, as-needed ICS-formoterol (Symbicort,
Budesonide-Formoterol) is recommended vs ICS-SABA
• In patients age 6 to 11 yo taking ICS every time the patient uses SABA.
• Becareful with the overuse of SABA >= 3 canisters per year increases risk of
asthma death.

12. Starting treatment
Step 1 - 2
As-needed Low dose ICS-
Formoterol
Reliever: As-needed Low dose ICS-Formoterol
Step 3
Low dose maintenance
ICS-Formoterol
Step 4
Medium dose
maintenance
ICS-Formoterol
Step 5
Add-on LAMA
Refer fro assessment of
phenotype. Consider high
dose maintenance ICS-
Formoterol, Anti IgE, Anti
IL5
Symptoms
Less
Than twice a
month
Symptoms
Most days
Or waking with
asthma once a week
Or more
Symptoms most days
Or waking with asthma
Once a week or more
And low lung function
Short course of OCS may
also be needed if severe
uncontrolled asthma

13. Starting Asthma Treatment
Doses
• Step 1 - 2 Budesonide - Formoterol 200/6 mcg dry powder inhaler taken when
ever needed for symptoms relief, or before exercise if needed. Max dose is
72mcg of formoterol.
• Step 3 low dose ICS-Formoterol (MART) Budesonide - Formoterol 200/6 mcg
dry powder inhaler 1 inhalation twice daily, plus 1 inhalation as needed.
• Step 4 Medium dose ICS - Formoterol as maintenance and reliever therapy. To
reach this we double the amount of inhalations for maintenance dose, but the
reliever still low dose. We can also add LAMA for patients older than 18yo “triple
inhaler”
• Step 5 refer to phenotypic investigation and add-on treatment.

14. Step 5
• Add on treatments:
• LAMA for patients >18 yo (>6y for tiotropium)
• Anti IgE (SC omalizumab >6yo) for severe allergic asthma
• Anti IL5 (SC mepolizumab >6yo) for severe eosinophilic type 2 asthma
• Anti TSLP (SC Tezepelumab) for severe asthma
• Add on azithromycin three days a week reduces exacerbations but
increases antibiotic resistance.

15. Reviewing response
• 1 to 3 months after starting treatment
• Then every 3 to 12 months
• During pregnancy every 4 to 6 weeks
• After exacerbation review visit within 1 week after event
• Depends on level of symptoms control

16. Good controlled Asthma
• Avoid troublesome day and night time symptmoms
• Patient uses little to no reliever medication
• Patient has an active and physical lives
• Patient has a normal to near normal pulmonary function tests
• Patient avoid serious exacerbations.

17. Assessing a patient with Asthma
1. Asthma control - Assess both symptom control and risk factors
• Assess symptoms control over the last 4 weeks
• Identify any modi
fi
able risk factors for poor outcome
• Measure lung functions before starting tx, 3-6 mo later and then periodically, eg annual
2. Assess multi morbidity
• Comorbidities including rhinitis, chronic rhino sinusitis, GERD, obesity, OSA, Depression and
anxiety
• They may contribute to respiratory symptoms
2. Treatment Issues
Record patient treatment, watch using inhaler, action plan,

18. Stepping Up
• Short term step up (for 1 to 2 weeks): during viral infections or expose to
allergens
• Sustained step up (for at least 2 to 3 months): if symptoms and exacerbations
persist for 2 to 3 months of ICS containing treatment assess issues before
considering step up

19. Stepping down
• Consider stepping down once good asthma control has been achieved and
maintained for 2 to 3 months. Find lowest dose to avoid side e
ff
ects.
• Choose appropriate time no URTI no pregnancy, no low lung functions.
• Written asthma action plan
• Make sure a follow up appointment is scheduled

20. Acute Asthma Exacerbation
• SABA + SAMA every 20 min for 1 hour
• Magnesium Sulfate IV
• Oxygen, Bipap if needed
• Systemic oral or IV corticosteroids