Global Initiative for Asthma Management

2009: Please visit: http://crisbertcualteros.page.tl

GLOBAL INITIATIVES FOR ASTHMA(GINA)

Initiated in 1989• US National Heart, Lung and Blood Institute• National Institute of Health• World Health Organization

OBJECTIVES:

• To increase appreciation for global public health perspectives of asthma• Recommend diagnostic and management strategies• Identify areas for future investigations

Objectives:Objectives: To present and compare the GINA 2002 with GINATo present and compare the GINA 2002 with GINA 2006-07 guidelines2006-07 guidelines

To update clinicians with the newer approach to To update clinicians with the newer approach to the management in childrenthe management in children

GINA ASTHMA GINA ASTHMA GUIDELINES:GUIDELINES:

20022002 2006-07 2006-07EMPHASIS: CLASSIFICATION ASTHMA MANAGEMENT OF PATIENT BY BASED ON CLINICAL

SEVERITY CONTROL

DEFINITION: IMPACT OF THE CLINICAL,PHYSIOLOGICAL DISEASE ON LUNG AND PATHOLOGICAL FUNCTION CHARACTERISTICS - airflow limitation - episodic shortness of - its reversibility breathing

- airway hyper- - wheezing responsiveness - cough

GINA ASTHMA GINA ASTHMA GUIDELINES:GUIDELINES:

20022002 2006-07 2006-07

PATHOLOGY: Acute and Chronic Inflammation

Inflammation is persistent

Inflammation affects all airways more in the medium sized bronchi

GINA ASTHMA GINA ASTHMA GUIDELINES:GUIDELINES:

20022002 2006 2006 -07-07

Pathophysiology: Airway Narrowing : - Airway smooth muscle contraction - Airway edema - Airway thickening - Mucus hypersecretion

Airway Hyperresponsiveness

GINA ASTHMAGINA ASTHMA GUIDELINESGUIDELINES::

20022002 2006 2006 - 07- 07

•Asthma is a chronic inflammatory disorder of the airways•is associated with airway hyperresponsiveness•recurrent episodes of wheezing•Breathlessness•chest tightness•coughing

GINA ASTHMA GUIDELINES:GINA ASTHMA GUIDELINES:20022002 2006-07 2006-07

Factors Influencing the Development and Expression of Asthma

HOST FACTORS Genetic, e.g., Genes pre-disposing to atopy Genes pre-disposing to airway hyperresponsiveness Obesity SexENVIRONMENTAL FACTORS Allergens Indoor: Domestic mites, furred animals(dogs, cats, mice) cockroach allergen, fungi, molds, yeast Outdoor: Pollens, fungi, molds, yeasts Infections (predominantly viral) Occupational sensitizers Tobacco smoke Passive smoking Active smoking Outdoor/Indoor Air Pollution Diet

GINA ASTHMA GUIDELINES 2002, 2006, 2007GINA ASTHMA GUIDELINES 2002, 2006, 2007

DIAGNOSIS:

Reversibility ofmeasurementsof lung function enhances confidencein making a diagnosis of asthma

Often prompted by symptoms: episodic breathlessness wheezing cough chest tightnessAssessment of the severity of airflowlimitationReversibility and variability confirms theDiagnosis of asthma

Asthma severity:Amount of dailymedications requiredfor optimal treatment

Asthma severity is measured NOTby severity of the underlying diseaseBUT its responsiveness to treatment

2002 2006 - 07

Measurement of allergic state helps to identifyRisk factors that causes asthma symptoms in patients

GINA ASTHMA GUIDELINES:GINA ASTHMA GUIDELINES:20022002 2006-07 2006-07

Clinical Control of asthma is defined as: • No (twice or less/week) daytime symptoms• No limitations of daily activities, including exercise• No nocturnal symptoms or awakening because of asthma• No (twice or less/week) need for reliever treatment• Normal or near normal lung function• No exacerbations

EMPHASIS: CLASSIFICATION ASTHMA MANAGEMENT OF PATIENT BY BASED ON CLINICAL SEVERITY CONTROL

20022002 2006 2006 - 07- 07

GINA GINA ASTHMAASTHMA GUIDELINES:GUIDELINES:

WHAT DETERMINES DISEASE WHAT DETERMINES DISEASE CLASSIFICATION IN GINA 2002 ?CLASSIFICATION IN GINA 2002 ?

Worst feature determines the Worst feature determines the severity classificationseverity classification

Useful when decisions are being Useful when decisions are being made about management at the made about management at the initial assessment of a patientinitial assessment of a patient

ASTHMA CONTROLASTHMA CONTROL(GINA 2006)(GINA 2006)

Refers to control of the clinical Refers to control of the clinical symptoms of the diseasesymptoms of the disease

Treatment is aimed at controlling the Treatment is aimed at controlling the clinical features of diseaseclinical features of disease

GINA ASTHMA GINA ASTHMA GUIDELINES:GUIDELINES:Questions to consider in the Diagnosis of Asthma

• 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 wheezing, chest tightness or cough after exposure to airborne allergens or pollutants?

• Do the patient’s colds “go to the chest” or take more than 10 days to clear up?

• Are symptoms improved by appropriate asthma treatment?

Classify Asthma Based on Classify Asthma Based on Severity:Severity:

Severity INTERMITTENT PERSISTENT

Mild Moderate Severe Daytime Symptoms < 1x a week 1x/wk Daily Daily Affects daily Limits daily activities activitiesNighttime Symptoms 2x/month >2x/month >1x/week Frequent

PEF 80% 80% >60-<79% <60% predicted predicted predicted predicted

PEF Variability 20% 20-30% >30% >30%

variability variability variabilityvariability

FEV1 80% 80% 60-79% <60%

(GINA 2002)

CharacteristicCharacteristic Controlled(All of the ff)Controlled(All of the ff) Partly Controlled (Any Partly Controlled (Any measure present in measure present in any week)any week)

UncontrolledUncontrolled

Daytime symptomsDaytime symptoms None (2x or </wk.)None (2x or </wk.) More than 2x/wkMore than 2x/wk Three or more Three or more features of partly features of partly controlled asthma controlled asthma present in any weekpresent in any week

Limitations of Limitations of activitiesactivities

None None AnyAny

Nocturnal symptoms/ Nocturnal symptoms/ awakeningawakening

NoneNone AnyAny

Need for Need for reliever/rescue txreliever/rescue tx

None (2x or less/week)None (2x or less/week) More than 2x/ wkMore than 2x/ wk

Lung function (PEF or Lung function (PEF or FEV1)FEV1)++

NormalNormal <80% predicted or <80% predicted or personal best (if personal best (if known)known)

Exacerbations Exacerbations NoneNone One or more/ yr*One or more/ yr* One in any wkOne in any wk╪╪

GINA ASTHMA GUIDELINES:GINA ASTHMA GUIDELINES:2006

Levels of Asthma Control

Asthma in Acute Exacerbation

GINA ASTHMA GINA ASTHMA GUIDELINES:GUIDELINES:

2002 2006-07

Severity of Asthma Exacerbations….. MILD MODERATE SEVERE RESPIRATORY

ARREST IMMINENT

Breathless Walking Talking At restInfants – softer Infants- Stopsshorter cry feeding

Can lie flat Prefers sitting *Hunched forward

Talks in Sentences Phrases Words

Alertness May be agitated Usually agitated Usually agitated

Respiratory Rate Increased Increased *Often >30/min Bradypnea

GUIDE TO RATES OF BREATHING ASSOCIATED WITHRESPIRATORY DISTRESS IN AWAKE CHILDREN

AGE NORMAL RATE > 2 months < 60/min 2-12 months < 50/min 1-5 years < 40/min 6-8 years < 30/min

GINA 2002, 2006, 2007

MILD MODERATE SEVERE RESPIRATORY ARREST IMMINENT

Accessory None Present Present Present Muscles & Thoraco-abdominal Suprasternal Movement Retraction

Wheeze Audible with Audible with Audible w/o Absence of wheeze stethoscope stethoscope stethoscope with decreased to

absent breathe sounds

Pulses/min <100 100-120 >120 Bradycardia

GUIDE TO LIMITS OF NORMAL PULSE RATE IN CHILDREN Age Normal Limits

Infants 2-12 months <160/minPreschool 1-2 years <120/minSchool Age 2-6 years <110/min

Severity of Asthma Exacerbations…..

GINA 2002, 2006, 2007

Severity of Asthma Exacerbations MILD MODERATE SEVERE RESPIRATORY

ARREST IMMINENT

Pulses Paradoxus Absent May be present Often present Absence suggests<10mm Hg 10—20mm Hg 20-40mm Hg respiratory muscle

fatigue

PEF 80% 60-79% <60%%predictedOr%personal best

PaO2 RA Normal 60mm Hg <60mmHgtest NOT usually Possible Cyanosisnecessary

PaCO2 45 mm Hg 45 mm Hg >45 mm Hg possiblerespiratory failure

SaO2 RA 95% 90-94% <90%

Hypercapnea (hypoventilation) develops more rapidly in young children

GINA 2002,2006,2007

GINA ASTHMA GUIDELINES: (2002, 2006,2007)GINA ASTHMA GUIDELINES: (2002, 2006,2007)Management of Asthma Exacerbation in Acute Care

Initial AssessmentHistory, Physical Examination(auscultation, use of accessory muscles, HR, RR, PEF or FEV1, O2 saturation, ABG’s if patient in extremis)

Initial TreatmentOxygen to achieve O2 saturation ≥90% (95% in children)Inhaled rapid β2-agonist continuously for one hourSystemic GCS, if no immediate response, or if patient recently tookOral GCS, of if episode is severeSEDATION is CONTRAINDICATED in the treatment of an exacerbation

Reassess after 1 hour : PE, PEF, O2 saturation & other tests as needed

Criteria for MODERATE Episode:• PEF 60-80% predicted/personal best• Physical exam: moderate symptoms,• Accessory muscle useTreatment: O2, Inhaled β2 agonist + anticholinergic every 60 minOral GCSContinue treatment for 1-3 hours,providedThere is improvement

Criteria for SEVERE Episode:• History of risk factors for near fatal asthma• PEF < 60% predicted/personal best• PE: severe symptoms at rest, chest retractionNO improvement after initial treatmentTreatment:O2,Inhaled β2 agonist + anticholinergicSystemic GCSIV Magnesium

Continuation next slide

S1

GINA ASTHMA GUIDELINES: (2002, 2006,2007)GINA ASTHMA GUIDELINES: (2002, 2006,2007)

Reassess after 1 – 2 hours

Good Response within 1-2 hours:Response sustained 60 minutes after last treatmentPE normal: no distressPEF > 70%O2 saturation > 90% (95% in children)

Incomplete Response within 1-2 hours:Risk Factors for near fatal asthmaPE : mild to moderate signsPEF < 60%O2 saturation: NOT IMPROVING

Poor Response within 1-2 hours:Risk factors fro near fatal asthmaPE : symptoms severe, drowsiness, confusionPEF : < 30%PCO2 : > 45mmHgPO2: < 60mmHg

ADMIT to ACUTE CARE Setting• Oxygen• Inhaled β2-agonist ± anticholinergic• Systemic GCS• Intravenous Magnesium•Monitor PEF, O2 saturation, Pulse

ADMIT to INTENSIVE Care• Oxygen• Inhaled β2-agonist+anticholinergic • IV GCS•Consider IV β2 agonist• Consider IV theophylline• Possible intubation • mechanical ventilation

Reassess at Intervals

Poor Response:• Admit to intensive CareIncomplete response in 6-12 hours• Consider admission to Intensive Care•If No improvement within hoursImproved

Improved: Criteria for Discharging HomePEF > 60% predicted / personal bestSustained on oral/inhaled medications

HOME TREATMENT:• Continue inhaled β2 agonist•Consider in most cases, oral GCS•Consider adding a combination inhaler•Patient education: take medicine correctly

review action plan close medical check up

Management of Asthma Exacerbation in Acute CareCont. (S2)

Inhaled Inhaled ββ22-agonists are -agonists are the mainstay of therapy the mainstay of therapy in acute asthma.in acute asthma.

However, once response to the initial However, once response to the initial ββ22-agonists is minimal, -agonists is minimal, incomplete or poor …incomplete or poor …

COMBINATION of INHALED COMBINATION of INHALED ββ22--AGONIST and INHALED AGONIST and INHALED ANTICHOLINERGIC is RECOMMENDEDANTICHOLINERGIC is RECOMMENDED

What is the role of Salbutamol – Ipratropium What is the role of Salbutamol – Ipratropium in acute asthmatic attacks?in acute asthmatic attacks?

INTERMITTENTINTERMITTENT

- no added benefit over Salbutamol alone - no added benefit over Salbutamol alone if attack is mildif attack is mild

However, However, any moderate to severeany moderate to severe attack of asthma regardless of attack of asthma regardless of severity classification can benefit severity classification can benefit from the combination.from the combination.

Medicines in Childhood AsthmaMedicines in Childhood AsthmaRelievers

Rapid-acting inhaled Beta (B)2 agonist

Inhaled anti-cholinergics

Short acting theophylline

Short acting B2 agonist

(SABA)

ControllersInhaled and systemic

corticosteroidsLeukotriene modifiersLong-acting B2

agonist (LABA) with Inhaled Corticosteroid ICS

Sustained release theophyllines

Cromones

GINA ASTHMA GUIDELINES 2002, 2006, 2007GINA ASTHMA GUIDELINES 2002, 2006, 2007

GINA ASTHMA GUIDELINES:GINA ASTHMA GUIDELINES:Recommended Medications by Level of Severity: Children

20022002

Daily ControllerMedications

Other TreatmentOptions

INTERMITTENT PERSISTENTMILD MODERATE SEVERE

• None necessary

• IGCS 100-400mcg BUD

IGCS 400-800µg BUD

•IGCS< 800µg BUD PLUSSustained releasedtheophylline OR

• IGCS <800µg BUD•PLUS LABA OR• IGCS >800µg OR•IGCS <800mcg PLUS • Leukotriene modifier

• IGCS >800µg BUD PLUS one or more of the following:

• Sustained- release theophylline

• Long Acting Inhaled β-2 agonist

• Leukotriene modifier

• Oral glucocortico steroid

• Sustained- release Theophylline, OR

• Cromone, OR• Leukotriene modifier

All Steps: In addition to daily controller therapy, rapid-acting inhaled β2 agonist* should be taken as needed to relieve symptoms, but should not be taken more than 3 to 4 times a day.

In all steps: Once control of asthma is achieved and maintained for at least 3months, a gradual reduction of the maintenance therapy should be tried in order to identify the minimum therapy required to maintain control

maintain and find lowest controlling step

consider stepping up to gain control

step up until controlled

treat as exacerbation

TREATMENT OF ACTIONTREATMENT OF ACTION

controlled

partly controlled

uncontrolled

exacerbation

LEVEL OF CONTROLLEVEL OF CONTROL

INC

REA

SER

EDU

CE

GINA 2006, 2007

GINA 2006, 2007

asthma educationasthma education

environmental controlenvironmental control

as needed rapid as needed rapid acting acting ββ2- 2-

agonistagonistas needed rapid acting as needed rapid acting ββ2- agonist2- agonist

SELECT ONESELECT ONE SELECT ONESELECT ONE ADD ONE OR MOREADD ONE OR MORE ADD ONE OR BOTHADD ONE OR BOTH

low-dose ICS*low-dose ICS* low-dose ICS low-dose ICS plus plus LABALABA

Medium- or high-dose Medium- or high-dose ICS ICS plus plus LABALABA

Oral gluco-Oral gluco-corticosteroidcorticosteroid

leukotriene leukotriene modifier**modifier**

Medium- or high-Medium- or high-dose ICSdose ICS

leukotriene modifierleukotriene modifier Anti-IgE treatmentAnti-IgE treatment

low-dose ICS low-dose ICS plus plus leukotriene modifierleukotriene modifier

sustained- release sustained- release theophyllinetheophylline

low-dose ICS low-dose ICS plus plus leukotriene modifierleukotriene modifierC

ON

TRO

LLER

O

PTIO

NS

* Inhaled glucocorticosteroid ** receptor antagonist or synthesis inhibitors

Inhaled Corticosteroids:Cornerstone in the Management

Of Asthma

GINA ASTHMA GUIDELINES 2002, GINA ASTHMA GUIDELINES 2002, 2006-072006-07

Inhaled CorticosteroidsInhaled Corticosteroids Most effective long-term control for persistent Most effective long-term control for persistent

asthmaasthma Small risk for adverse events at recommended Small risk for adverse events at recommended

dosagedosage Benefits of daily useBenefits of daily use

• Reduction ofReduction of asthma symptomsasthma symptoms frequency of exacerbationsfrequency of exacerbations airway inflammationairway inflammation airway responsivenessairway responsiveness asthma mortalityasthma mortality

• Improvement of Improvement of lung functionlung function quality of lifequality of life

Inhaled Corticosteroids Adverse Inhaled Corticosteroids Adverse EventsEvents

Small risk for adverse events at Small risk for adverse events at recommended dosesrecommended doses

Reduce potential for adverse events Reduce potential for adverse events by:by:• Using spacerUsing spacer• Rinsing mouthRinsing mouth

Maintenance Therapy:GINA ASTHMA GUIDELINES 2002, 2006, 2007GINA ASTHMA GUIDELINES 2002, 2006, 2007

2002 2006 2007

IGCS + LABA

Not mentionedAs form of therapy

Not recommendedFor children ≤ 5 years

As maintenance and rescueMedication has shown to reduce exacerbations in children ≥ 4 years with moderate & severe asthma

Estimated Equipotent Daily Doses of Inhaled Corticosteroids for Children

Drug Low Daily Dose Medium Daily Dose High Daily Dose (µg) (µg) (µg)

Beclomethasone 100 – 200 >200 – 400 >400Dipropionate

Budesonide 100-200 >200- 400 >400

Ciclesonide 80-160 >160-320 >320

Flunisolide 500-750 > 750-1250 > 1250

Fluticasone 100-200 > 200 – 500 >500

Mometasone 100-200 >200 – 500 >400furoateTriamcinolone 400-800 >800 – 1200 > 1200acetonide

GINA ASTHMA GUIDELINES 2002,2006-GINA ASTHMA GUIDELINES 2002,2006-0707

Choosing an Inhaler Device for Children with Asthma

Age Group Preferred device Alternate Device

Younger than 4 years Pressurized metered Nebulizer with face dose inhaler plus mask dedicated spacer with face mask

4 – 6 years Pressurized metered Nebulizer with dose inhaler plus mouth piece dedicated spacer with mouth piece

Older than 6 years Dry powder inhaler, Nebulizer with mouth or breath-actuated piece pressurized metered- dose inhaler or pressurized metered

dose inhaler with spacer mouth piece

Leukotriene Pathway

““ADD-ON” Treatment ADD-ON” Treatment OptionOption

GINA ASTHMA GINA ASTHMA GUIDELINES:GUIDELINES:

2002 2006-07 LEUKOTRIENE MODIFIER

Controller Option

LEUKOTRIENE MODIFIERLEUKOTRIENE MODIFIERChildren Younger than 5 YearsChildren Younger than 5 Years

Provide clinical benefit at all levels of Provide clinical benefit at all levels of severity (but less than ICS)severity (but less than ICS)

Partial protection against exercise-induced Partial protection against exercise-induced bronchoconstriction within hours after bronchoconstriction within hours after administrationadministration

Add on in children where asthma is Add on in children where asthma is insufficiently controlled by low dose of ICSinsufficiently controlled by low dose of ICS

Provide clinical benefit at all levels of severity (but Provide clinical benefit at all levels of severity (but less than ICS)less than ICS)

Partial protection against exercise-induced Partial protection against exercise-induced bronchoconstriction within hours after administrationbronchoconstriction within hours after administration

Add on in children where asthma is insufficiently Add on in children where asthma is insufficiently controlled by low dose of ICScontrolled by low dose of ICS

Reduce viral induced asthma exacerbationReduce viral induced asthma exacerbation

LEUKOTRIENE MODIFIERChildren Older than 5 Years

Montelukast+Budesonide vs. Montelukast+Budesonide vs. Double Dose of BudesonideDouble Dose of Budesonide

Price, D.B. et. Al., Thorax 2003; 58: 211-216

Montelukast vs. Corticosteroid Montelukast vs. Corticosteroid based on Quality of Lifebased on Quality of Life

Price, D.B. et. Al., Thorax 2003; 58: 211-216

Salamat!Salamat!