Global Strategy for Asthma Management and Prevention

Media Backgrounder
On World Asthma Day, May 6, 2014, the Global Initiative for Asthma (GINA) is
launching a major revision of its Global Strategy for Asthma Management and
Prevention. This comprehensive and practical resource about one of the most
common chronic lung diseases worldwide contains extensive citations from the
scientific literature and forms the basis for other GINA documents and programs.
The GINA strategy report was first published in 1993. Over the past decade it has
been updated annually, based on a twice-yearly review of scientific literature by
an international panel of experts on the GINA Science Committee. This is the first
major revision of the report in eight years. This media backgrounder summarizes
the major changes and new areas of content included in the report.
Definition of Asthma
The 2014 Global Strategy for Asthma Management and Prevention defines
asthma as follows:
Asthma is a heterogeneous disease, usually characterized by chronic airway
inflammation. It is defined by the history of respiratory symptoms such as
wheeze, shortness of breath, chest tightness, and cough that vary over time and
in intensity, together with variable expiratory airflow limitation.
The GINA Science Committee crafted this definition to portray the characteristics
that are typical of asthma and highlight the features that distinguish it from other
lung diseases.
The definition means that asthma is:
characterized by recurrent respiratory symptoms especially wheezing,
shortness of breath, chest tightness, and coughing.
heterogeneous its symptoms and their intensity are different from person
to person. Most people with asthma have signs of inflammation in the
airways of their lungs.
variable the symptoms wax and wane over time for each individual with
asthma. Measurements of lung function also vary over time.

Diagnosis of Asthma
The 2014 revision emphasizes the need for health care providers to confirm the
diagnosis of asthma in their patients in order to avoid both under- and overtreatment.
A key strategy for confirming the diagnosis of asthma is lung function testing,
preferably spirometry. This brief, painless test is performed in a doctors office or
lung function laboratory and measures a patients forced expiratory volume in
one second (FEV1). In individuals with asthma, FEV1 can be lower than normal,
reflecting the fact that their airways are inflamed and air does not move easily
into and out of the lungs.
The GINA strategy report contains specific advice about how to document lung
function abnormalities that are variable over time or reversible with treatment in
order to confirm a diagnosis of asthma. A more specialized test of airway hyperresponsiveness, or twitchiness of the airways, can also be helpful to confirm the
diagnosis of asthma. The report also details how to confirm the diagnosis in
special populations including smokers, the elderly, and patients already on
treatment.
Assessment of Asthma Control
The report reflects the current scientific understanding that asthma control has
two components: symptom control and future risk. This means that a persons
asthma is under good control when he or she has:

No (or minimal) asthma symptoms.

No waking at night due to asthma.
No (or minimal) need to use reliever medication.
The ability to do normal physical activity and exercise.
Normal (or near-normal) lung function test results.
No (or very infrequent) asthma attacks.
Low risk of future asthma attacks or other negative outcomes.

The meaning of asthma symptom control is generally understood among both

patients and health care providers. Future risk is a newer concept, though it has
been endorsed by GINA since 2009. To build widespread familiarity with this
concept, the report details the many factors that need to be considered when
evaluating future risk. A few examples include a persons history of severe
asthma attacks, smoking, side effects of asthma medications, and how regularly
a person takes their asthma medication as prescribed.

Asthma Management
GINA endorses a comprehensive approach to asthma management that is based
on a continuous cycle of assessment, treatment, and review. This cycle is a
widely accepted concept in asthma management. As in previous versions, the
report emphasizes that inhaled corticosteroids are the foundation of long-term
asthma management. However, this version of the report provides more detailed
guidance about individualizing therapy based on a patients characteristics, risk
factors, and preferences, as well as the availability of medications and structure
of the health care system in different parts of the world.
Asthma is treated in a stepwise manner based on the number and dose of
medications necessary to maintain control of the disease. This stepwise
treatment system is very similar to previous versions of the report. However, this
version contains specific advice to help clinicians troubleshoot issues like
incorrect inhaler technique and the failure of patients to always adhere to their
medication regimen as prescribed. Addressing these common problems can
often help avoid the need to step up treatment.
Providing asthma education and teaching correct inhaler technique is important
for all individuals with asthma. However, the report also emphasizes the need to
adapt treatment recommendations to take into account the health literacy,
ethnicity, cultural beliefs, and availability of medications to individual patients.
Management of Worsening Asthma and Exacerbations
The report lays out a streamlined yet comprehensive approach to care for
patients with worsening asthma and exacerbations, or flare-ups. This system
begins with self-management according to a written asthma action plan, and
progresses if necessary through primary care management and acute care in the
emergency department or hospital.
In this section and throughout the report, there are substantial changes to the
structure and layout of the report, with many new tables and flow-charts to
communicate key messages for clinical practice. The GINA Science Committee
has designed these figures, tables, and flowcharts to provide greater clarity and
usefulness for busy clinicians at all levels.

Management of Asthma in Children 5 Years and Younger

The report includes a chapter on management of asthma in young children. Much
of this material was published as a separate report in 2009. Bringing it into the
main report means that a single document covers diagnosis and management of
asthma across all age groups.
Diagnosis of Asthma, COPD, and Asthma-COPD Overlap Syndrome
This new chapter in the report is a joint effort between GINA and the Global
Initiative for Chronic Obstructive Lung Disease (GOLD). It is necessary because
distinguishing asthma from chronic obstructive pulmonary disease (COPD) can
be problematic, especially in smokers and older adults. This discussion reflects
the evolving scientific understanding that diseases of the airways in the lungs are
a continuum and sometimes involve related risk factors and disease processes.
The chapter aims to help clinicians identify patients who have chronic airways
disease; distinguish between asthma, COPD, and the Asthma-COPD Overlap
Syndrome; and decide on next steps whether initial treatment or referral to a
specialist.