Prepara tus exámenes y mejora tus resultados gracias a la gran cantidad de recursos disponibles en Docsity
Gana puntos ayudando a otros estudiantes o consíguelos activando un Plan Premium
Prepara tus exámenes
Prepara tus exámenes y mejora tus resultados gracias a la gran cantidad de recursos disponibles en Docsity
Prepara tus exámenes con los documentos que comparten otros estudiantes como tú en Docsity
Encuentra los documentos específicos para los exámenes de tu universidad
Estudia con lecciones y exámenes resueltos basados en los programas académicos de las mejores universidades
Responde a preguntas de exámenes reales y pon a prueba tu preparación
Consigue puntos base para descargar
Gana puntos ayudando a otros estudiantes o consíguelos activando un Plan Premium
Comunidad
Pide ayuda a la comunidad y resuelve tus dudas de estudio
Ebooks gratuitos
Descarga nuestras guías gratuitas sobre técnicas de estudio, métodos para controlar la ansiedad y consejos para la tesis preparadas por los tutores de Docsity
Guía de bolsillo GINA 2015
Tipo: Guías, Proyectos, Investigaciones
1 / 32
Esta página no es visible en la vista previa
¡No te pierdas las partes importantes!
BASED ON THE GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION
© Global Initiative for Asthma
Asthma affects an estimated 300 million individuals worldwide. It is a serious global health problem affecting all age groups, with increasing prevalence in many developing countries, rising treatment costs, and a rising burden for patients and the community. Asthma still imposes an unacceptable burden on health care systems, and on society through loss of productivity in the workplace and, especially for pediatric asthma, disruption to the family.
Health care providers managing asthma face different issues around the world, depending on the local context, the health system, and access to resources.
The Global Initiative for Asthma (GINA) was established to increase awareness about asthma among health professionals, public health authorities and the community, and to improve prevention and management through a coordinated worldwide effort. GINA prepares scientific reports on asthma, encourages dissemination and implementation of the recommendations, and promotes international collaboration on asthma research.
The Global Strategy for Asthma Management and Prevention was extensively revised in 2014 to provide a comprehensive and integrated approach to asthma management that can be adapted for local conditions and for individual patients. It focuses not only on the existing strong evidence base, but also on clarity of language and on providing tools for feasible implementation in clinical practice. The report was updated in 2015.
This Pocket Guide is a brief summary of the GINA 2015 report for primary health care providers. It does NOT contain all of the information required for managing asthma, for example, about safety of treatments, and should be used in conjunction with the full GINA 2015 report. GINA cannot be held liable or responsible for healthcare administered with the use of this document, including any use which is not in accordance with applicable local or national regulations or guidelines.
The GINA 2015 report and other GINA publications (listed on page 28) can be obtained from www.ginasthma.org.
Asthma is a disease with many variations (heterogeneous), usually characterized by chronic airway inflammation. Asthma has two key defining features:
A flow-chart for making the diagnosis in clinical practice is shown in Box 1, with the specific criteria for diagnosing asthma in Box 2.
Box 1. Diagnostic flow-chart for asthma in clinical practice
The diagnosis of asthma should be confirmed and, for future reference, the evidence documented in the patient’s notes. Depending on clinical urgency and access to resources, this should preferably be done before starting controller treatment. Confirming the diagnosis of asthma is more difficult after treatment has been started (see p 7 ).
Box 2. Features used in making the diagnosis of asthma
1. A history of variable respiratory symptoms Typical symptoms are wheeze, shortness of breath, chest tightness, cough - People with asthma generally have more than one of these symptoms - The symptoms occur variably over time and vary in intensity - The symptoms often occur or are worse at night or on waking - Symptoms are often triggered by exercise, laughter, allergens or cold air - Symptoms often occur with or worsen with viral infections 2. Evidence of variable expiratory airflow limitation - At least once during the diagnostic process when FEV 1 is low, document that the FEV 1 /FVC ratio is reduced. The FEV 1 /FVC ratio is normally more than 0.75–0.80 in adults, and more than 0.90 in children. - Document that variation in lung function is greater than in healthy people. For example: o FEV 1 increases by more than 12% and 200mL (in children, >12% of the predicted value) after inhaling a bronchodilator. This is called ‘bronchodilator reversibility’. o Average daily diurnal PEF variability* is >10% (in children, >13%) o FEV 1 increases by more than 12% and 200mL from baseline (in children, by >12% of the predicted value) after 4 weeks of anti- inflammatory treatment (outside respiratory infections) - The greater the variation, or the more times excess variation is seen, the more confident you can be of the diagnosis - Testing may need to be repeated during symptoms, in the early morning, or after withholding bronchodilator medications. - Bronchodilator reversibility may be absent during severe exacerbations or viral infections. If bronchodilator reversibility is not present when it is first tested, the next step depends on the clinical urgency and availability of other tests. - For other tests to assist in diagnosis, including bronchial challenge tests, see Chapter 1 of the GINA 2015 report.
*Calculated from twice daily readings (best of 3 each time), as ([the day’s highest PEF minus the day’s lowest PEF]) divided by the mean of the day’s highest and lowest PEF, and averaged over 1-2 weeks. If using PEF at home or in the office, use the same PEF meter each time.
Physical examination in people with asthma is often normal, but the most frequent finding is wheezing on auscultation, especially on forced expiration.
If standard criteria for asthma (Box 2) are not met, consider other investigations. For example, if lung function is normal, repeat reversibility testing after withholding medications for 12 hours. If the patient has frequent symptoms, consider a trial of step-up in controller treatment and repeat lung function testing after 3 months. If the patient has few symptoms, consider stepping down controller treatment, but ensure the patient has a written asthma action plan, monitor them carefully, and repeat lung function testing.
Take every opportunity to assess patients with a diagnosis of asthma, particularly when they are symptomatic or after a recent exacerbation, but also when they ask for a prescription refill. In addition, schedule a routine review at least once a year.
Box 3. How to assess a patient with asthma
1. Asthma control – assess both symptom control and risk factors - Assess symptom control over the last 4 weeks (Box 4, p9) - Identify any other risk factors for poor outcomes (Box 4) - Measure lung function before starting treatment, 3–6 months later, and then periodically, e.g. yearly 2. Treatment issues - Record the patient’s treatment (Box 7, p14), and ask about side-effects - Watch the patient using their inhaler, to check their technique (p18) - Have an open empathic discussion about adherence (p18) - Check that the patient has a written asthma action plan (p22) - Ask the patient about their attitudes and goals for their asthma 3. Are there any comorbidities? - These include rhinitis, rhinosinusitis, gastroesophageal reflux (GERD), obesity, obstructive sleep apnea, depression and anxiety. - Comorbidities should be identified as they may contribute to respiratory symptoms and poor quality of life. Their treatment may complicate asthma management.
Asthma control means the extent to which the effects of asthma can be seen in the patient, or have been reduced or removed by treatment. Asthma control has two domains: symptom control (previously called ‘current clinical control’) and risk factors for future poor outcomes.
Poor symptom control is a burden to patients and a risk factor for flare-ups. Risk factors are factors that increase the patient’s future risk of having exacerbations (flare-ups), loss of lung function, or medication side-effects.
Box 4. Assessment of symptom control and future risk
A. Level of asthma symptom control
In the past 4 weeks, has the patient had : (^) controlledWell controlled^ Partly^ Uncontrolled Daytime symptoms more than twice/week? Yes No None of these
of these
of these
Any night waking due to asthma? Yes No Reliever needed* more than twice/week? Yes No Any activity limitation due to asthma? Yes No B. Risk factors for poor asthma outcomes Assess risk factors at diagnosis and periodically, particularly for patients experiencing exacerbations. Measure FEV 1 at start of treatment, after 3–6 months of controller treatment to record personal best lung function, then periodically for ongoing risk assessment. Potentially modifiable independent risk factors for exacerbations include:
Having one or more of these risk factors increases the risk of exacerbations even if symptoms are well controlled.
The long-term goals of asthma management are symptom control and risk reduction. The aim is to reduce the burden to the patient and their risk of exacerbations, airway damage, and medication side-effects. The patient’s own goals regarding their asthma and its treatment should also be identified.
Population-level recommendations about ‘preferred’ asthma treatments represent the best treatment for most patients in a population.
Patient-level treatment decisions should take into account any individual characteristics or phenotype that predict the patient’s likely response to treatment, together with the patient’s preferences and practical issues such as inhaler technique, adherence, and cost.
A partnership between the patient and their health care providers is important for effective asthma management. Training health care providers in communication skills may lead to increased patient satisfaction, better health outcomes, and reduced use of health care resources.
Health literacy – that is, the patient’s ability to obtain, process and understand basic health information to make appropriate health decisions – should be taken into account in asthma management and education.
Treatment of asthma for symptom control and risk reduction includes:
Asthma treatment is adjusted in a continuous cycle to assess , adjust treatment and review response. The main components of this cycle are shown in Box 6.
Box 6. The control-based asthma management cycle
Box 7. Stepwise approach to asthma treatment
*For children 6–11 years, theophylline is not recommended, and the preferred Step 3 treatment is medium dose ICS. **Low dose ICS/formoterol is the reliever medication for patients prescribed low dose budesonide/formoterol or low dose beclometasone/formoterol
For medication Glossary, see p 26. For details about treatment recommendations, supporting evidence, and clinical advice about implementation in different populations see the full GINA 2015 report (www.ginasthma.org).
Box 8. Low, medium and high daily doses of inhaled corticosteroids (mcg)
Inhaled corticosteroid Adults and adolescents Children 6–11 years Low Medium High Low Medium High Beclometasone dipropionate (CFC)* 200 – 500 >500– 1000 >1000 100 – 200 >200– 400 > Beclometasone dipropionate (HFA) 100 – 200 > 200 – 400 >400 50 - 100 >100- 200 > Budesonide (DPI) 200 – 400 >400– 800 >800 100 – 200 >200– 400 > Budesonide (nebules) 250 – 500 >500– 1000 > Ciclesonide (HFA) 80 – 160 >160– 320 >320 80 >80- 160 > Fluticasone propionate( DPI) 100 – 250 >250– 500 > 500 100 – 200 >200– 400 > Fluticasone propionate (HFA) 100 – 250 >250– 500 >500 100 – 200 >200– 500 > Mometasone furoate 110 – 220 >220– 440 >440 110 ≥220–<440 ≥ Triamcinolone acetonide 400 – 1000 >1000– 2000 >2000 400 – 800 >800– 1200 > CFC: chlorofluorocarbon propellant; DPI: dry powder inhaler; HFA: hydrofluoroalkane propellant. *Included for comparison with older literature.
COPYRIGHTED MATERIAL - DO NOT ALTER OR REPRODUCE
Once asthma treatment has been started, ongoing decisions are based on a cycle to assess, adjust treatment and review response. The preferred treatments at each step are summarized below and in Box 7 (p14); for details, see full GINA 2015 report. See Box 8 (p 14 ) for ICS dose categories.
STEP 1 : As-needed SABA with no controller (this is indicated only if symptoms are rare, there is no night waking due to asthma, no exacerbations in the last year, and normal FEV 1 ). Other options : regular low dose ICS for patients with exacerbation risks.
STEP 2: Regular low dose ICS plus as-needed SABA Other options : LTRA are less effective than ICS; ICS/LABA leads to faster improvement in symptoms and FEV 1 than ICS alone but are more expensive and the exacerbation rate is similar. For purely seasonal allergic asthma, start ICS immediately and cease 4 weeks after end of exposure.
STEP 3: Low dose ICS/LABA either as maintenance treatment plus as- needed SABA, or as ICS/formoterol maintenance and reliever therapy For patients with ≥1 exacerbation in the last year, low dose BDP/formoterol or BUD/formoterol maintenance and reliever strategy is more effective than maintenance ICS/LABA with as-needed SABA. Other options : Medium dose ICS Children (6–11 years) : Medium dose ICS. Other options: low dose ICS/LABA
STEP 4: Low dose ICS/formoterol maintenance and reliever therapy, or medium dose ICS/LABA as maintenance plus as-needed SABA Other options : Add-on tiotropium by soft-mist inhaler for adults (≥18 years) with a history of exacerbations; high dose ICS/LABA, but more side-effects and little extra benefit; extra controller, e.g. LTRA or slow-release theophylline (adults) Children (6–11 years): Refer for expert assessment and advice.
STEP 5: Refer for expert investigation and add-on treatment Add-on treatments include anti-IgE (omalizumab) for severe allergic asthma. Sputum-guided treatment, if available, improves outcomes. Other options : Add-on tiotropium by soft-mist inhaler for adults (≥18 years) with a history of exacerbations. Some patients may benefit from low dose OCS but long-term systemic side-effects occur.
Provide skills training for effective use of inhaler devices
Most patients (up to 80%) cannot use their inhaler correctly. This contributes to poor symptom control and exacerbations. To ensure effective inhaler use:
Information about inhaler devices and techniques for their use can be found on the GINA website (www.ginasthma.org) and the ADMIT website (www.admit-inhalers.org).
Check and improve adherence with asthma medications
Around 50% of adults and children do not take controller medications as prescribed. Poor adherence contributes to poor symptom control and exacerbations. It may be unintentional (e.g. forgetfulness, cost, misunderstandings) and/or non-intentional (e.g. not perceiving the need for treatment, fear of side-effects, cultural issues, cost).
To identify patients with adherence problems:
Only a few adherence interventions have been studied closely in asthma.
Exacerbation risk can be minimized by optimizing asthma medications, and by identifying and treating modifiable risk factors. Some examples of risk modifiers with consistent high quality evidence are:
In addition to medications, other therapies and strategies may be considered where relevant, to assist in symptom control and risk reduction. Some examples with consistent high quality evidence are:
Although allergens may contribute to asthma symptoms in sensitized patients, allergen avoidance is not recommended as a general strategy for asthma. These strategies are often complex and expensive, and there are no validated methods for identifying those who are likely to benefit.
Some common triggers for asthma symptoms (e.g. exercise, laughter) should not be avoided, and others (e.g. viral respiratory infections, stress) are difficult to avoid and should be managed when they occur.
