2020 GINA GUIDELINES ON THE

MANAGEMENT OF ASTHMA
 1. Objectives

2. GINA defined

3. Defining and diagnosing asthma

OUTLINE 4. Identifying control

5. Management of asthma among different age groups

6. Interim guidance during the COVID-19 pandemic

 To b e a b l e t o p r e s e n t t h e l a t e s t g u i d e l i n e s
GENERAL OBJECTIVE on the management of Asthma based on the
GINA report.
 1. To be able to define what GINA is.

2. To be able to define what asthma is and to

discuss its basic pathophysiology.

3. To be able to discuss how to diagnose asthma

among the different age groups.
SPECIFIC OBJECTIVES 4. To be able to discuss how to identify patient’s
level of asthma control.

5. To be able to discuss the particular management

of asthma among the different age groups.

6. To be able to discuss the GINA interim

guidance during the COVID-19 pandemic.
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• Established to increase awareness about
GINA asthma.

Global Initiative for Asthma • Prepares scientific reports on asthma.

• Encourages dissemination and

implementation of the recommendations.

• Promotes international collaboration on

asthma research.
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PATHOPHYSIOLOGY:

ASTHMA Chronic inflammation

• a syndrome characterized by airflow Airways are sensitive

obstruction that varies markedly Bronchospasm/constriction
• AIRWAY INFLAMMATION Mucus plugging

• 2 key defining features: S/Sx of Asthma

• a history of respiratory symptoms that vary
over time and intensity
• variable expiratory airflow limitation
Most COMMON trigger: DUSTMITE/DERMATOPHAGOIDES

Most POTENT trigger: VIRAL INFECTION

DIAGNOSING ASTHMA

EVIDENCE OF VARIABLE
HISTORY OF VARIABLE
EXPIRATORY AIRFLOW
RESPIRATORY SYMPTOMS
LIMITATION

SPIROMETRY
• Wheezing
• Shortness of breath Reversibility is demonstrated by a >12%
• Chest tightness and > 200 ml increase in FEV1 from
• Cough baseline (Pedia: > 12% of the predicted
value) after inhaling a bronchodilator
ASTHMA IN THE YOUNGER POPULATION

A diagnosis of asthma in young children with a history of wheezing is more likely if they have:
• Wheezing or coughing that occurs with exercise, laughing or crying or in the absence of apparent
respiratory infection.
• A history of other allergic disease, allergen sensitization or asthma in first-degree relatives.
• Clinical improvement during 2-3 months of controller treatment and worsening after cessation.
ASSESSING ASTHMA CONTROL

Asthma control pertains to the extent to which the effects of asthma can be seen in the patient or
have been reduced or removed by treatment.
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LUNG FUNCTION SEVERITY

MONITORING CLASSIFICATION
Recorded upon diagnosis, 3-6 months after MILD – well-controlled with STEP 1 or 2
starting treatment and periodically thereafter:
MODERATE – well-controlled with STEP 3
• At least every 1-2 years
SEVERE – requires STEP 4 or 5 treatment
• More often in children and those at higher
risk of flare-ups or lung function decline
GINA ASSESSMENT OF ASTHMA CONTROL IN CHILDREN 5 YEARS AND
BELOW

In the past 4 weeks, has the child had:

• Daytime asthma symptoms for more than a few minutes, more than once a week?

• Any activity limitation due to asthma? (Runs/plays less than other children, tires easily during
walks/playing?)

• Reliever medication needed more than once a week? (EXCEPT reliever taken before exercise)

• Any night waking or night coughing due to asthma?

NONE OF THESE YES TO 1-2 OF THESE YES TO 3-4 OF THESE

WELL-CONTROLLED PARTIALLY CONTROLLED UNCONTROLLED
GINA ASSESSMENT OF ASTHMA CONTROL IN PATIENTS 6 YEARS OLD
AND ABOVE

In the past 4 weeks, has the patient had:

• Daytime symptoms for more than twice a week?

• Any night waking due to asthma?

• SABA reliever needed more than twice a week?

• Any activity limitation due to asthma?

NONE OF THESE YES TO 1-2 OF THESE YES TO 3-4 OF THESE

WELL-CONTROLLED PARTIALLY CONTROLLED UNCONTROLLED
 KEY POINTS:
• Long-term goals of asthma management are to
achieve good symptom control and to minimize
MANAGING ASTHMA AMONG future risk of asthma-related mortality,
exacerbations, persistent airflow limitation and
DIFFERENT AGE GROUPS treatment side effects.

• Asthma treatment is adjusted in a continuous cycle

of assessment, treatment and review of patient’s
response.
CHILDREN 5 YEARS AND BELOW

• The goal of asthma management in young children are similar to those in older patients.

• Wheezing episodes in young children should be treated initially with inhaled short-acting B2 agonist
every 4-6H PRN until symptoms disappear, usually within 1-7 days, regardless of whether the diagnosis
of asthma has been made.

• A trial of controller therapy should be given if the symptom pattern suggests asthma, alternative diagnoses
have been excluded and respiratory symptoms are uncontrolled and/or wheezing episodes are frequent or
severe.
CHILDREN 5 YEARS AND BELOW
• Response to treatment should be reviewed before deciding whether to continue it. If the response is absent
or incomplete, reconsider alternative diagnoses.

• The choice of inhaler device should be based on the child’s age and capability. The preferred device is a
pressurized metered dose inhaler with spacer, with:
 Face mask: < 3 YO
 Mouthpiece: most 3-5 YO

• Children should be switched from a face mask to mouth piece as soon as they are able demonstrate good
technique.

• Review the need for asthma treatment frequently, as asthma-like symptoms remit in many young children.
LOW DOSES OF INHALED CORTICOSTEROIDS (ICS) FOR CHILDREN
5 YEARS AND BELOW
MANAGEMENT OF WORSENING ASTHMA AND EXACERBATIONS IN
CHILDREN 5 YEARS AND YOUNGER

Early symptoms of exacerbation may include:

• Increased symptoms
• Increased coughing especially at night
• Lethargy or reduced exercise tolerance
• Impaired daily activities
• Poor response to relievers
MANAGEMENT OF WORSENING ASTHMA AND EXACERBATIONS IN
CHILDREN 5 YEARS AND YOUNGER

• Initial home treatment is with inhaled SABA, with review after 1 hour or earlier.

• Medical attention should be sought the same day if inhaled SABA is needed more often than 3-hourly
or for more than 24 hours.

• In primary care/acute care facility, assess severity of exacerbation while initiating treatment with SABA (2-
6 puffs q 20 mins for the 1st hour) and O2 to maintain sats at 94-98%.
MANAGEMENT OF WORSENING ASTHMA AND EXACERBATIONS IN
CHILDREN 5 YEARS AND YOUNGER

• Recommend immediate transfer to the hospital if there is no response to inhaled SABA within 1-2 hours; if
the child is unable to speak or drink, with RR >40 /min or is cyanosed, if resources are lacking in the home,
or if O2 saturation is < 92% on RA.

• Consider PO prednisone/prednisolone 1-2 mg/kg/day for up to 5 days for children in the ED or is admitted
in the hospital, up to a maximum of 20 mg/day for 0-2 YO and 30 mg/day for 3-5 YO.

• May also consider dexamethasone 0.6 mg/kg/day for 2 days. If there is failure of resolution or relapse of
symptoms with dexamethasone, consider switching to prednisolone.
PATIENTS 6 YEARS OLD AND ABOVE

• GINA no longer recommends treatment of asthma in adolescents and adults with SABA alone.

• All adults and adolescents with asthma should receive ICS-containing controller treatment to reduce their
risk of serious exacerbations and to control symptoms.
PATIENTS 6 YEARS OLD AND ABOVE

FOR STEPS 1 and 2

• Treatment with regular low-dose ICS, with PRN SABA, is highly effective in reducing asthma symptoms,
exacerbations, hospitalization and death.

• In adolescents and adults with mild asthma, treatment with PRN low-dose ICS-Formoterol (LABA)
reduces the risk for severe exacerbation by about 2/3 compared to SABA-only treatment.
PATIENTS 6 YEARS OLD AND ABOVE

STEPPING-UP

• Check first for common problems such as improper inhaler technique, poor adherence, persistent allergen
exposure and co-morbidities.

• For patients 6-11 years, Step 3 options include medium dose ICS and combination low-dose ICS-LABA as
maintenance therapy with PRN SABA.

• For adolescents and adults, the preferred step-up treatment is a combination low dose ICS-LABA.
PATIENTS 6 YEARS OLD AND ABOVE

STEPPING-DOWN

• Consider stepping-down once good asthma control has been achieved and maintained for about 3 months
to find the patient’s lowest treatment that controls both symptoms and exacerbations.
MANAGEMENT OF WORSENING ASTHMA AND EXACERBATIONS IN
PATIENTS 6 YEARS AND OLDER

• Assess severity by the degree of dyspnea, RR, HR, O2 Sats and lung function, while starting SABA and O2
therapy.

• Arrange transfer to an acute care facility if there are signs of severe exacerbation, or to intensive care if the
patient is drowsy, confused or has a silent chest.

• During transfer, give inhaled SABA and ipratropium bromide, controlled O2 and systemic corticosteroids.
MANAGEMENT OF WORSENING ASTHMA AND EXACERBATIONS IN
PATIENTS 6 YEARS AND OLDER

• Start treatment with repeated administration of SABA, early introduction of PO corticosteroids and
controlled flow O2 if available. Re-assess after 1 hour.

• Give ipratropium bromide only for severe exacerbations. Consider IV MgSO4 for patients with severe
exacerbations not responding to initial treatment.

• Do not routinely request for a chest x-ray and do not routinely prescribe antibiotics for asthma
exacerbations.
INTERIM GUIDANCE ON ASTHMA
MANAGEMENT DURING THE
COVID-19 PANDEMIC
INTERIM GUIDANCE ON ASTHMA MANAGEMENT DURING THE COVID-
19 PANDEMIC

• Advise patients with asthma to continue taking their prescribed asthma medications, particularly
inhaled corticosteroids (ICS) medications and oral corticosteroids (OCS) if prescribed.

• Make sure that all patients have a written asthma action plan.

• When possible, avoid using nebulizers due to the risk of transmitting infection to healthcare
workers and other patients.
INTERIM GUIDANCE ON ASTHMA MANAGEMENT DURING THE COVID-
19 PANDEMIC

• Avoid spirometry in patients with confirmed/suspected COVID-19.

• Follow infection control recommendations if other aerosol-generating procedures are needed.

• Follow local health advice about hygiene strategies and use of personal protective equipment.
THANK YOU