INitiative for
A sthma
GINA Workshop Report
Topics:
Definition
Burden of Asthma
Risk Factors
Mechanisms
Research Recommendations
Definition of Asthma
INFLAMMATION
Airway
Hyperresponsiveness Airflow Obstruction
International Study of
Asthma and Allergies in
Children (ISAAC)
Lancet 1998;351:1225
Increasing Prevalence of Asthma in
Children/Adolescents
Finland
{1966
(Haahtela et al)
1989
Sweden
{1979
(Aberg et al)
1991
Japan
{1982
(Nakagomi et al)
1992
Scotland
{1982
(Rona et al)1992
UK
{1989
(Omran et al)
1994
USA
(NHIS) {1982
1992
New Zealand 1975
{1989
(Shaw et al)
Australia
{1982
(Peat et al)1992
0 5 10 15 20 25 30 35
Prevalence (%)
Trends in Prevalence of Asthma
By Age, U.S., 1985-1996
80 Rate/1,000 Persons
Age (years)
70
<18
60 18-44
45-64
50 65+
Total (All Ages)
40
30
20
85 86 87 88 89 90 91 92 93 94 95 96
Year
Hospitalization Rates for Asthma
by Age, U.S., 1974 - 1997
Rate/100,000 Persons
40
35 <15
30 15-44
45-64
25
65+
20
15
10
5
0
74 76 78 80 82 84 86 88 90 92 94 96
Year
Death Rates for Asthma
By Race, Sex, U.S., 1980-1998
Rate/100,000 Persons
5
Black Female
4
Black Male
3
White Female
White Male
1
0
1980 1985 1990 1995 2000
Year
Risk Factors for Asthma
Allergens
Air Pollutants
Respiratory infections
Exercise and hyperventilation
Weather changes
Sulfur dioxide
Food, additives, drugs
Risk Factors that Lead to
Asthma Development
1. Educate Patients
2. Assess and Monitor Severity
3. Avoid Exposure to Risk Factors
4. Establish Medication Plans for
Chronic Management: Adults and
Children
5. Establish Plans for Managing
Exacerbations
6. Provide Regular Follow-up Care
Six-Part Asthma Management
Program
1. Educate patients to develop a partnership in
asthma management
2. Assess and monitor asthma severity with
symptom reports and measures of lung
function as much as possible
3. Avoid exposure to risk factors
4. Establish medication plans for chronic
management in children and adults
5. Establish individual plans for managing
exacerbations
6. Provide regular follow-up care
Six-part Asthma Management Program
Control of Asthma
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
Six-part Asthma Management Program
Factors Associated with
Non-Compliance in Asthma Care
Symptom reports
Use of reliever medication
Nighttime symptoms
Activity limitations
Spirometry for initial assessment. Peak Expiratory Flow for
follow-up:
Assess severity
Assess response to therapy
PEF monitoring at home
Important for those with poor perception of symptoms
Daily measurement recorded in a diary
Assesses the severity and predicts worsening
Guides the use of a zone system for asthma self-management
Arterial blood gas for severe exacerbations
Typical Spirometric (FEV1)
Tracings
Volume
FEV1
Normal Subject
1 2 3 4 5
Time (sec)
Note: Each FEV1 curve represents the highest of three repeat measurements
A Simple Index of PEF Variation
700
PEF (L/min)
600
500
300
0 7 14
Days
Pharmacologic Therapy
Controller Medications:
Inhaled glucocorticosteroids
Systemic glucocorticosteroids
Cromones
Methylxanthines
Leukotriene modifiers
Anti-IgE
Part 4: Long-term Asthma Management
Pharmacologic Therapy
Reliever Medications:
Rapid-acting inhaled β2-agonists
Systemic glucocorticosteroids
Anticholinergics
Methylxanthines
Short-acting oral β2-agonists
Estimated Comparative Daily Dosages
for Inhaled Glucocorticosteroids
Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
Adult Child Adult Child Adult Child
Flunisolde 500-1000 500 -750 1000-2000 750-1250 > 2000 > 1250
Fluticasone 100- 250 100-200 250- 500 200- 400 > 500 > 400
Mometasone 200- 400 400- 800 > 800
furoate
Triamcinolone 400- 1000 400-800 1000-2000 800-1200 > 2000 > 1200
acetonide
Part 4: Long-term Asthma Management
Stepwise Approach to Asthma
Therapy - Adults
Outcome: Asthma Control Outcome: Best
Possible Results
Controller:
Daily inhaled
corticosteroid
plus
Controller: When
Daily long – asthma is
Controller: Daily inhaled acting inhaled controlled,
Controller: Daily inhaled corticosteroid β2-agonist reduce
None plus plus (if needed) therapy
corticosteroid
Daily long- -Theophylline-SR
acting inhaled -Leukotriene
β2-agonist Monitor
-Long-acting inhaled
β2- agonist
-Oral corticosteroid
- Sustained-release theophylline
- Leukotriene modifier
- Long-acting inhaled β2- agonist
- Oral glucocorticosteroid
Initial Therapy
Bronchodilators; O2 if needed
Good Response
Incomplete/Poor Response Respiratory Failure
Controller:
Daily inhaled
corticosteroid
Controller: Daily long – When
acting inhaled asthma is
Controller: Daily inhaled β2-agonist controlled,
Controller: Daily inhaled corticosteroid reduce
plus(if needed) therapy
None corticosteroid Daily long-
acting inhaled -Theophylline-SR
β2-agonist -Leukotriene
Monitor
-Long-acting inhaled
β2- agonist
-Oral corticosteroid