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GINA 2014 concise edition




Asthma Is a heterogeneous disease, usually characterized by chronic airway inflammationIt is defined by the history of respiratory symptomsWheeze Shortness of breathChest tightnessCough Symptoms vary over time and in intensity, together with variable expiratory airflow limitationVariations are triggered by factors such as exercise, allergen or irritant exposure, change in weather, or viral respiratory infections

Airway hyperresonsiveness2Asthma phenotypeASTHMA PHENOTYPEDESCRIPTIONAllergic asthmaStarts in childhood, with hx of allergic diseases (eczema, rhinitis); responds well to ICSNon-allergic asthmaMay be eosinophilic/neutrophilic or few inflammatory cells (paucigranulocytic); responds less well to ICSLate-onset asthmaAdults (women), non-allergic; requires higher doses of ICS (relatively refractory)Asthma with fixed airflow limitation Thought to be due to airway wall remodelingAsthma with obesity Prominent respiratory symptoms and little eosinophilic airway inflammationAsthma of recognizable clusters of demographic, clinical and/or pathophysiological characteristics3DIAGNOSING ASTHMAIncreases risk of px having asthma>1 symptom (wheeze, shortness of breath, cough, chest tightness), especially in adultsSymptoms often worse at night or early in the morningSymptoms vary over time and in intensitySymptoms are triggered by viral infections (common colds), exercise, allergen exposure, changes in weather, laughter or irritants (car exhaust fumes, smoke or strong smells)

Decreases risk of px having asthmaIsolated cough with no other respiratory symptoms Chronic production of sputumShortness of breath associated with dizziness, light-headedness or peripheral tingling (paresthesia)Chest painExercise-induced dyspnea with noisy inspirationDiagnosing AsthmaRespiratory symptoms such as wheezing, dyspnea, chest tightness, coughVariable expiratory airflow limitation

DIAGNOSTIC FEATURECRITERIA1. History of variable respiratory symptoms Wheezes, shortness of breath, chest tightness and coughGenerally more than one type of respiratory symptomSx occur variably over time and vary in intensitySx are often worse at night or on wakingSx are often triggered by exercise, laughter, allergens, cold airSx often appear or worsen with viral infectionsDIAGNOSTIC FEATURECRITERIA2. Confirmed variable expiratory airflow limitation Documented excessive variability in lung function

AND documented airflow limitationThe greater the variations, or the more occasions excess variation is seen, the more confident the diagnosis

At least once during diagnostic process when FEV1 is low, confirm that FEV1/FVC is reduced (normally >0.75-0.80 in adults, >0.90 in children)Positive bronchodilator (BD) reversibility test (more likely positive if BD medication is withheld before test: SABA 4h, LABA 15hAdults: increase in FEV1 of >12% and >200 ml from baseline, 10-15 minutes after 200-400 mcg albuterol or equivalent (greater confidence if increase is >15% and >400 ml)Children: increase in FEV1 of >12% predictedExcessive variability in 2x-daily PEF over two weeksAdults: average daily diurnal PEF variability >10%Children: average daily diurnal PEF variability >13%DIAGNOSTIC FEATURECRITERIA2. Confirmed variable expiratory airflow limitation Significant increase in lung function after 4 weeks of anti-inflammatory treatment Adults: Increase in FEV1 >12% or >200 ml from baseline after 4 weeks of treatment, outside of respiratory infectionsPositive exercise challenge testAdults: fall in FEV1 of >10% and >200 ml from baselineChildren: fall in FEV1 of >12% predicted, or PEF >15%Positive bronchial challenge test (usually only performed in adults)Fall in FEV1 from baseline of 20% with standard doses of methacholine or histamine, or 15% with standardized hyperventilation , hypertonic saline or mannitol challengeExcessive variation in lung function between visits (less reliable)Adults: variation in FEV1 of >12% and >200 ml between visits, outside of respiratory infectionsChildren: variation in FEV1 of >12% in FEV1 or >15% in PEF between visitsHistory and PEThere is an increased risk that respiratory problems are due to asthma if :Respiratory symptoms start in childhoodHistory of allergic rhinitis or eczemaFamily history of asthma or allergyNonspecific

PEOften normalMost frequent abnormality is expiratory wheezing (rhonchi) on auscultation (this may be absent or heard only on forced expiration) Wheezing may also be absent in severe asthma exacerbations due to severely reduced flow (silent chest)Wheezing may also be heard in upper airway obstruction, COPD, tracheomalacia, respiratory infection, and foreign bodyPECrackles (crepitations) and inspiratory wheezing are not features of asthmaExamination of nose may reveal rhinitis or nasal polyposisFEV1 (Forced Expiratory Volume) Lung disease or poor spirometric techniqueReduced ratio of FEV1 to FVC - indicates airflow limitationNormal: FEV1/FVC >0.75-0.80; >0.90 in childrenOnce an obstructive defect has been confirmed, variation in airflow limitation is generally assessed from variation in FEV1 or PEFVARIABILITY refers to improvement and/or deterioration of symptoms and lung functionREVERSIBILITYrefers to rapid improvements in FEV1 or PEF measured within minutes after inhalation of a rapid-acting bronchodilator or more sustained improvement over days or weeks after the introduction of effective controller treatment How much variation in expiratory airflow is consistent with asthma?The greater the variations in their lung function, or the more times excess variation is seen, the more likely the diagnosis is asthmaIn adults with typical respiratory systems of asthma, an increase or decrease in FEV1 of >12% and >200 ml of baseline (if spirometry is not available) a change of PEF of at least 20%OTHER TESTSBronchial provocation test this test helps assess airway hyperresponsivenessAllergy tests allergen test or sIgE sIgE is preferred for uncooperative patients, those with widespread skin disease, or hx suggests anaphylaxis)Exhaled NO FENO is increased in eosinophilic asthma but also in non-asthma conditions (e.g. eosinophilic bronchitis, atopy and allergic rhinitis). AgeConditionSymptoms6-11 yearsChronic upper airway cough syndrome Inhaled foreign bodyBronchiectasisPrimary ciliary dyskinesia

12-39 years40+ years

How to step down controller treatment to help confirm the dx of asthma20ASSESSMENT OF ASTHMAAssessment of asthma should include the assessment of asthma control (both symptom control and future risk of adverse outcomes)Ms X has good asthma symptom control, but she is at risk of increased of future exacerbations because she has had a severe exacerbation within the last year

Asthma sx control tools in 6-11 y/oBased on symptoms, limitation of activities and use of rescue medication

Assessing Risk of adverse outcomesAssess whether the patient is at risk of adverse asthma outcome ExacerbationsFixed airflow limitation Side effects of medication Assessing Asthma SeverityMILD well controlled in Step 1or 2 treatment with as-needed reliever medication alone or with low intensity controller treatmentMODERATE well controlled in Step 3 treatment SEVERE requires Step 4 or Step 5 treatment TREATMENTLong-term goalsTo achieve good control of symptoms and maintain normal activity levelsTo minimize future risk of exacerbations, fixed airflow limitation and side effects

ASTHMA MEDICATIONSController medications: used for regular maintenance treatment. They reduce airway inflammation, control sx, and reduce future risks such as exacerbations and decrease in lung functionReliever (rescue) medications: as-needed relief for breakthrough symptoms, also recommended for short-term prevention of exercise-induced bronchoconstriction. REDUCING AND IDEALLY ELIMINATING RELIEVER TX IS BOTH AN IMPT GOAL IN ASTHMA MGT AND A MEASURE OF SUCCESS OF ASTHMA TXAdd-on therapies for px with severe asthma: for px with persistent sx and severe exacerbations, despite optimized tx of high-dose controlled medications Initial Controller Treatment Regular daily controller should be started as soon as asthma is diagnosed, because:Early initiation of low dose ICS in px with asthma leads to greater improvement in lung function than if sx have been present for >2-4 yearsPatients not taking ICS who experience a severe exacerbation have a greater long-term decline in lung function than those who have already started ICSFor px with occupational asthma, early removal from exposure to the sensitizing agent and early tx increase the probability of recovery1`

Stepwise approachOnce tx has started: assessment adjustment review of response Controller medication is adjusted up or down in a stepwise approachOnce asthma has been controlled in 2-3months, tx may be stepped down in order to find patients minimum effective txIf px has persisting sx despite 2-3 months of controller tx, assessIncorrect inhaler techniquePoor adherencePersistent exposure at home/work such as allergens, tobacco smoke, indoor or outdoor air pollution, or medications such as beta-blockers, or NSAIDSComorbidities that may contribute to respiratory sx and poor quality of lifeIncorrect diagnosis

STEP 1AS NEEDED-RELIEVER INHALERPreferred option As-needed inhaled SABA insufficient evidence in safety of using alone, thus preferred in px with occasional daytime sx of short duration, with no night waking and with normal lung fxn. If not, regular controller tx is neededOther option Regular low dose ICS in addition to SABAOther options not recommended for routine useInhaled anticholinergic (ipratropium)Oral SABAOral acting theophylline

But with slower set of action and higher side effectsThe rapid onset LABA, formeterol, is as effective as SABA in reliever medic