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G IN A. lobal itiative for sthma. GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION (Revised 2006). GINA Program Objectives. Increase appreciation of asthma as a global public health problem Present key recommendations for diagnosis and management of asthma

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GINA

lobal

itiative for

sthma


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GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION

(Revised 2006)


Gina program objectives

GINA Program Objectives

  • Increase appreciation of asthma as a global public health problem

  • Present key recommendations for diagnosis and management of asthma

  • Provide strategies to adapt recommendations to varying health needs, services, and resources

  • Identify areas for future investigation of particular significance to the global community


Executive committee chair paul o byrne md

GINA Structure

Executive CommitteeChair: Paul O’Byrne, MD

Dissemination/Implementation Task Group

Chair: Wan Tan, MD

Science

Committee

Chair: Eric Bateman, MD


Gina executive committee

GINA Executive Committee

P. O’Byrne, Chair, Canada

E. Bateman, S. Africa S. Pedersen, Denmark

J. Bousquet, FranceR. Singh, India

T. Clark, UK M. Soto-Quiroz, Costa Rica

K. Ohta, Japan W. Tan, Canada

P. Paggario,Italy


Gina science committee

GINA Science Committee

E. Bateman, Chair,S. Africa

P. Barnes, UK K. Ohta, Japan

J. Bousquet, FranceS. Pedersen, Denmark

J. Drazen, US E. Pizzichini, Brazil

M. FitzGerald, CanadaS. Sullivan, US

P. Gibson, Australia S. Wenzel, US

P. O’Byrne, Canada H. Zar,S. Africa


Executive committee chair paul o byrne md1

GINA Structure

Executive CommitteeChair: Paul O’Byrne, MD

Science

Committee

Chair: Eric Bateman, MD

Dissemination/Implementation Task Group

Chair: Wan Tan, MD

GINA ASSEMBLY


Gina assembly

GINA Assembly

  • A network of individuals participating in the dissemination and implementation of asthma management programs at the local, national and regional level

  • GINA Assembly members are invited to meet with the GINA Executive Committee during the ATS and ERS meetings


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Bangladesh

Saudi Arabia

Slovenia

Germany

Ireland

Yugoslavia

Australia

Croatia

Canada

Brazil

Austria

Taiwan ROC

United States

Portugal

Thailand

Malta

Greece

Moldova

Mexico

China

Syria

South Africa

United Kingdom

Hong Kong

New Zealand

Italy

Chile

Venezuela

Argentina

Israel

Lebanon

Pakistan

Japan

GINA Assembly

Poland

Korea

Netherlands

Switzerland

Georgia

Russia

Macedonia

France

Czech

Republic

Denmark

Turkey

Slovakia

Belgium

Singapore

Spain

Colombia

Ukraine

Romania

India

Sweden

Vietnam

Kyrgyzstan

Albania


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GINA Documents

  • Global Strategy for Asthma Management and Prevention (revised 2006)

  • Pocket Guide: Asthma Management and Prevention (revised 2006)

  • Pocket Guide: Asthma Management and Prevention in Children (revised 2006)

  • Guide for asthma patients and families

    All materials are available on GINA web site www.ginasthma.org


Global strategy for asthma management and prevention

Global Strategy for Asthma Management and Prevention

  • Evidence-based

  • Implementation oriented

    Diagnosis

    Management

    Prevention

  • Outcomes can be evaluated


Global strategy for asthma management and prevention1

Global Strategy for Asthma Management and Prevention

Evidence Category Sources of Evidence

ARandomized clinical trials

Rich body of data

BRandomized clinical trials

Limited body of data

CNon-randomized trials

Observational studies

DPanel judgment consensus


Global strategy for asthma management and prevention 2006

Global Strategy for Asthma Management and Prevention (2006)

  • Definition and Overview

  • Diagnosis and Classification

  • Asthma Medications

  • Asthma Management and Prevention Program

  • Implementation of Asthma Guidelines in Health Systems

Revised 2006


Definition of asthma

Definition of Asthma

  • A chronic inflammatory disorder of the airways

  • Many cells and cellular elements play a role

  • Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing

  • Widespread, variable, and often reversible airflow limitation


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Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, MD


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Source: Peter J. Barnes, MD

Mechanisms: Asthma Inflammation


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Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, MD


Burden of asthma

Burden of Asthma

  • Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals

  • Prevalence increasing in many countries, especially in children

  • A major cause of school/work absence


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Asthma Prevalence and Mortality

Source: Masoli M et al. Allergy 2004


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Countries should enter their own data on burden of asthma.


Risk factors for asthma

Risk Factors for Asthma

  • Host factors: predispose individuals to, or protect them from, developing asthma

  • Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist


Factors that exacerbate asthma

Factors that Exacerbate Asthma

  • Allergens

  • Respiratory infections

  • Exercise and hyperventilation

  • Weather changes

  • Sulfur dioxide

  • Food, additives, drugs


Factors that influence asthma development and expression

Factors that Influence Asthma Development and Expression

Host Factors

  • Genetic

    - Atopy

    - Airway hyperresponsiveness

  • Gender

  • Obesity

  • Environmental Factors

  • Indoor allergens

  • Outdoor allergens

  • Occupational sensitizers

  • Tobacco smoke

  • Air Pollution

  • Respiratory Infections

  • Diet


Is it asthma

Is it Asthma?

  • Recurrent episodes of wheezing

  • Troublesome cough at night

  • Cough or wheeze after exercise

  • Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants

  • Colds “go to the chest” or take more than 10 days to clear


Asthma diagnosis

Asthma Diagnosis

  • History and patterns of symptoms

  • Measurements of lung function

    - Spirometry

    - Peak expiratory flow

  • Measurement of airway responsiveness

  • Measurements of allergic status to identify risk factors

  • Extra measures may be required to diagnose asthma in children 5 years and younger and the elderly


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Typical Spirometric (FEV1) Tracings

Volume

FEV1

Normal Subject

Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)

1

2

3

4

5

Time (sec)

Note: Each FEV1 curve represents the highest of three repeat measurements


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Measuring Variability of Peak Expiratory Flow


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Measuring Airway Responsiveness


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Clinical Control of Asthma

  • No (or minimal)* daytime symptoms

  • No limitations of activity

  • No nocturnal symptoms

  • No (or minimal) need for rescue medication

  • Normal lung function

  • No exacerbations

    _________

    * Minimal = twice or less per week


Levels of asthma control

Levels of Asthma Control


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Revised 2006

Asthma Management and Prevention

Program: Five Components

1.Develop Patient/Doctor Partnership

2. Identify and Reduce Exposure to Risk Factors

3. Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations

5. Special Considerations


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Asthma Management and Prevention Program: Five Interrelated Components

1. Develop Patient/Doctor Partnership

2. Identify and Reduce Exposure to Risk Factors

3. Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations

5. Special Considerations


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Asthma Management and Prevention Program

Goals of Long-term Management

  • Achieve and maintain control of symptoms

  • Maintain normal activity levels, including exercise

  • Maintain pulmonary function as close to normal levels as possible

  • Prevent asthma exacerbations

  • Avoid adverse effects from asthma medications

  • Prevent asthma mortality


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Asthma Management and Prevention Program

  • Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms

  • Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.


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Asthma Management and Prevention Program

  • Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control


Asthma management and prevention program component 1 develop patient doctor partnership

Asthma Management and Prevention ProgramComponent 1: Develop Patient/Doctor Partnership

  • Guidelines on asthma management should be available but adapted and adopted for local use by local asthma planning teams

  • Clear communication between health care professionals and asthma patients is key to enhancing compliance


Asthma management and prevention program component 1 develop patient doctor partnership1

Asthma Management and Prevention ProgramComponent 1: Develop Patient/Doctor Partnership

  • Educate continually

  • Include the family

  • Provide information about asthma

  • Provide training on self-management skills

  • Emphasize a partnership among health care providers, the patient, and the patient’s family


Asthma management and prevention program component 1 develop patient doctor partnership2

Asthma Management and Prevention ProgramComponent 1: Develop Patient/Doctor Partnership

Key factors to facilitate communication:

  • Friendly demeanor

  • Interactive dialogue

  • Encouragement and praise

  • Provide appropriate information

  • Feedback and review


Asthma management and prevention program factors involved in non adherence

Asthma Management and Prevention ProgramFactors Involved in Non-Adherence

  • Non-Medication Factors

  • Misunderstanding/lack of information

  • Fears about side-effects

  • Inappropriate expectations

  • Underestimation of severity

  • Attitudes toward ill health

  • Cultural factors

  • Poor communication

Medication Usage

  • Difficulties associated with inhalers

  • Complicated regimens

  • Fears about, or actual side effects

  • Cost

  • Distance to pharmacies


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Asthma Management and Prevention Program

Component 2: Identify and Reduce Exposure to Risk Factors

  • Measures to prevent the development of asthma, and asthma exacerbations by avoiding or reducing exposure to risk factors should be implemented wherever possible.

  • Asthma exacerbations may be caused by a variety of risk factors – allergens, viral infections, pollutants and drugs.

  • Reducing exposure to some categories of risk factors improves the control of asthma and reduces medications needs.


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Asthma Management and Prevention Program

Component 2: Identify and Reduce Exposure to Risk Factors

  • Reduce exposure to indoor allergens

  • Avoid tobacco smoke

  • Avoid vehicle emission

  • Identify irritants in the workplace

  • Explore role of infections on asthma development, especially in children and young infants


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Asthma Management and Prevention Program

Influenza Vaccination

  • Influenza vaccination should be provided to patients with asthma when vaccination of the general population is advised

  • However, routine influenza vaccination of children and adults with asthma does not appear to protect them from asthma exacerbations or improve asthma control


Asthma management and prevention program component 3 assess treat and monitor asthma

Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma

The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional


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Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma

  • Depending on level of asthma control, the patient is assigned to one of five treatment steps

  • Treatment is adjusted in a continuous cycle driven by changes in asthma control status. The cycle involves:

    - Assessing Asthma Control

    - Treating to Achieve Control

    - Monitoring to Maintain Control


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Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma

  • A stepwise approach to pharmacological therapy is recommended

  • The aim is to accomplish the goals of therapy with the least possible medication

  • Although in many countries traditional methods of healing are used, their efficacy has not yet been established and their use can therefore not be recommended


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Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma

  • The choice of treatment should be guided by:

  • Level of asthma control

  • Current treatment

  • Pharmacological properties and availability of the various forms of asthma treatment

  • Economic considerations

    Cultural preferences and differing health care

    systems need to be considered


Levels of asthma control1

Levels of Asthma Control


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Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma

  • The choice of treatment should be guided by:

  • Level of asthma control

  • Current treatment

  • Pharmacological properties and availability of the various forms of asthma treatment

  • Economic considerations

    Cultural preferences and differing health care

    systems need to be considered


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Component 4: Asthma Management and Prevention Program

Controller Medications

  • Inhaled glucocorticosteroids

  • Leukotriene modifiers

  • Long-acting inhaled β2-agonists

  • Systemic glucocorticosteroids

  • Theophylline

  • Cromones

  • Long-acting oral β2-agonists

  • Anti-IgE

  • Systemic glucocorticosteroids


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Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age

Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)

> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y


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Component 4: Asthma Management and Prevention Program

Reliever Medications

  • Rapid-acting inhaled β2-agonists

  • Systemic glucocorticosteroids

  • Anticholinergics

  • Theophylline

  • Short-acting oral β2-agonists


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Component 4: Asthma Management and PreventionProgramAllergen-specific Immunotherapy

  • Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis

  • The role of specific immunotherapy in asthma is limited

  • Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma

  • Perform only by trained physician


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LEVEL OF CONTROL

TREATMENT ACTION

REDUCE

maintain and find lowest controlling step

controlled

consider stepping up to gain control

partly controlled

uncontrolled

step up until controlled

INCREASE

exacerbation

treat as exacerbation

REDUCE

INCREASE

TREATMENT STEPS

STEP

1

STEP

2

STEP

3

STEP

4

STEP

5


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Treating to Achieve Asthma Control

  • Step 1 – As-needed reliever medication

  • Patients with occasional daytime symptoms of short duration

  • A rapid-acting inhaled β2-agonist is the recommended reliever treatment (Evidence A)

  • When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher)


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Treating to Achieve Asthma Control

  • Step 2 – Reliever medication plus a single controller

  • A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (Evidence A)

  • Alternative controller medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids


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Treating to Achieve Asthma Control

  • Step 3 – Reliever medication plus one or two controllers

  • For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting β2-agonist either in a combination inhaler device or as separate components (Evidence A)

  • Inhaled long-acting β2-agonist must not be used as monotherapy

  • For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)


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Treating to Achieve Asthma Control

  • Additional Step 3 Options for Adolescents and Adults

  • Increase to medium-dose inhaled glucocorticosteroid (Evidence A)

  • Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)

  • Low-dose sustained-release theophylline (Evidence B)


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Treating to Achieve Asthma Control

  • Step 4 – Reliever medication plus two or more controllers

  • Selection of treatment at Step 4 depends on prior selections at Steps 2 and 3

  • Where possible, patients not controlled on Step 3 treatments should be referred to a health professional with expertise in the management of asthma


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Treating to Achieve Asthma Control

  • Step 4 – Reliever medication plus two or more controllers

  • Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence A)

  • Medium- or high-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)

  • Low-dose sustained-release theophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence B)


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Treating to Achieve Asthma Control

  • Step 5 – Reliever medication plus additional controller options

  • Addition of oral glucocorticosteroids to other controller medications may be effective (Evidence D) but is associated with severe side effects (Evidence A)

  • Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)


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Treating to Maintain Asthma Control

  • When control as been achieved, ongoing monitoring is essential to:

    - maintain control

    - establish lowest step/dose treatment

  • Asthma control should be monitored by the health care professional and by the patient


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Treating to Maintain Asthma Control

Stepping down treatment when asthma is controlled

  • When controlled on medium- to high-dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals (Evidence B)

  • When controlled on low-dose inhaled glucocorticosteroids: switch to once-daily dosing (Evidence A)


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Treating to Maintain Asthma Control

Stepping down treatment when asthma is controlled

  • When controlled on combination inhaled glucocorticosteroids and long-acting inhaled β2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting β2-agonist (Evidence B)

  • If control is maintained, reduce to low-dose inhaled glucocorticosteroids and stop long-acting β2-agonist (Evidence D)


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Treating to Maintain Asthma Control

Stepping up treatment in response to loss of control

  • Rapid-onset, short-acting or long-acting inhaled β2-agonist bronchodilators provide temporary relief.

  • Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy


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Treating to Maintain Asthma Control

Stepping up treatment in response to loss of control

  • Use of a combination rapid and long-acting inhaled β2-agonist (e.g., formoterol) and an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a controller and reliever is effective in maintaining a high level of asthma control and reduces exacerbations (Evidence A)

  • Doubling the dose of inhaled glucocortico-steroids is not effective, and is not recommended (Evidence A)


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Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger

Childhood and adult asthma share the same underlying mechanisms. However, because of processes of growth and development, effects of asthma treatments in children differ from those in adults.


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Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger

Many asthma medications (e.g. glucocorticosteroids, β2- agonists, theophylline) are metabolized faster in children than in adults, and younger children tend to metabolize medications faster than older children


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Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger

  • Long-term treatment with inhaled glucocorticosteroids has not been shown to be associated with any increase in osteoporosis or bone fracture

  • Studies including a total of over 3,500 children treated for periods of 1 – 13 years have found no sustained adverse effect of inhaled glucocorticosteroids on growth


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Asthma Management and Prevention ProgramComponent 3: Assess, Treat and Monitor Asthma – Children 5 Years and Younger

  • Rapid-acting inhaled β2-agonists are the most effective reliever therapy for children

  • These medications are the most effective bronchodilators available and are the treatment of choice for acute asthma symptoms


Asthma management and prevention program component 4 manage asthma exacerbations

Asthma Management and Prevention ProgramComponent 4: Manage Asthma Exacerbations

  • Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness

  • Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)

  • Severe exacerbations are potentially life-threatening and treatment requires close supervision


Asthma management and prevention program component 4 manage asthma exacerbations1

Asthma Management and Prevention ProgramComponent 4: Manage Asthma Exacerbations

Treatment of exacerbations depends on:

  • The patient

  • Experience of the health care professional

  • Therapies that are the most effective for the particular patient

  • Availability of medications

  • Emergency facilities


Asthma management and prevention program component 4 manage asthma exacerbations2

Asthma Management and Prevention ProgramComponent 4: Manage Asthma Exacerbations

Primary therapies for exacerbations:

  • Repetitive administration of rapid-acting inhaled β2-agonist

  • Early introduction of systemic glucocorticosteroids

  • Oxygen supplementation

    Closely monitor response to treatment with serial

    measures of lung function


Asthma management and prevention program special considerations

Asthma Management and Prevention ProgramSpecial Considerations

Special considerations are required to

manage asthma in relation to:

  • Pregnancy

  • Surgery

  • Rhinitis, sinusitis, and nasal polyps

  • Occupational asthma

  • Respiratory infections

  • Gastroesophageal reflux

  • Aspirin-induced asthma

  • Anaphylaxis and Asthma


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Asthma Management and Prevention Program:Summary

  • Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms

  • Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control


Asthma management and prevention program summary

Asthma Management and Prevention Program:Summary

  • A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication

  • The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered


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http://www.ginasthma.org


Thank you

Thank you.


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Alternate Slides for Asthma Treatment


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Levels of Asthma Control

* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate.

† By definition, an exacerbation in any week makes that an uncontrolled asthma week.


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Asthma Control: Treatment Steps

Children Older than Five Years, Adolescents, Adults


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