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GUIA DE ASMA
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GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION

Global Strategy for Asthma Management and Prevention (2018 update)

The reader acknowledges that this report is intended as an evidence-based asthma management strategy, for the use of health professionals and policy-makers. It is based, to the best of our knowledge, on current best evidence and medical knowledge and practice at the date of publication. When assessing and treating patients, health professionals are strongly advised to use their own professional judgment, and to take into account local or national regulations and guidelines. GINA cannot be held liable or responsible for inappropriate healthcare associated with the use of this document, including any use which is not in accordance with applicable local or national regulations or guidelines.

This document should be cited as: Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2018. Available from: www.ginasthma.org

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TABLE OF CONTENTS Tables and figures ..................................................................................................................................................... 5 Preface ..................................................................................................................................................................... 7 Members of GINA committees (2017) ....................................................................................................................... 8 Methodology ............................................................................................................................................................ 9 What’s new in GINA 2018? ...................................................................................................................................... 11 Peer-reviewed publications about the GINA report ................................................................................................. 12 SECTION 1. ADULTS, ADOLESCENTS AND CHILDREN 6 YEARS AND OLDER ............................................................. 13

Chapter 1. Definition, description, and diagnosis of asthma .................................................................................... 13 Definition of asthma .................................................................................................................................................. 14 Description of asthma ................................................................................................................................................ 14 Making the initial diagnosis ....................................................................................................................................... 15 Differential diagnosis ................................................................................................................................................. 20 Making the diagnosis of asthma in special populations ............................................................................................ 21 Chapter 2. Assessment of asthma ............................................................................................................................ 25 Overview .................................................................................................................................................................... 26 Assessing asthma symptom control ..........................................................................................................................27 Assessing future risk of adverse outcomes ............................................................................................................... 31 Role of lung function in assessing asthma control .................................................................................................... 31 Assessing asthma severity .........................................................................................................................................33 Chapter 3. Treating asthma to control symptoms and minimize risk ......................................................................... 35 Part A. General principles of asthma management ..................................................................................................... 36 Long-term goals of asthma management .................................................................................................................. 36 The patient-health care provider partnership ........................................................................................................... 37 Control-based asthma management ......................................................................................................................... 38 Part B. Medications and strategies for symptom control and risk reduction ............................................................. 41 Asthma medications .................................................................................................................................................. 41 Reviewing response and adjusting treatment ........................................................................................................... 49 Treating other modifiable risk factors ....................................................................................................................... 51 Other therapies .......................................................................................................................................................... 52 Non-pharmacological interventions .......................................................................................................................... 53

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Indications for referral for expert advice .................................................................................................................. 56 Part C. Guided asthma self-management education and skills training ..................................................................... 57 Overview .................................................................................................................................................................... 57 Skills training for effective use of inhaler devices .....................................................................................................57 Adherence with medications and other advice ......................................................................................................... 58 Asthma information................................................................................................................................................... 59 Training in guided asthma self-management ............................................................................................................ 60 Part D.

Managing asthma with comorbidities and in special populations ............................................................. 63

Managing comorbidities ............................................................................................................................................ 63 Managing asthma in special populations or settings ................................................................................................ 66 Chapter 4. Management of worsening asthma and exacerbations ............................................................................... 73 Overview .................................................................................................................................................................... 75 Diagnosis of exacerbations ........................................................................................................................................ 75 Self-management of exacerbations with a written asthma action plan ................................................................... 76 Management of asthma exacerbations in primary care ........................................................................................... 79 Management of asthma exacerbations in the emergency department ................................................................... 82 Chapter 5. Diagnosis and initial treatment of asthma, COPD and asthma-COPD overlap (ACO) ............................... 89 Objective .................................................................................................................................................................... 90 Background to diagnosing asthma, COPD and asthma-COPD overlap ...................................................................... 91 Definitions.................................................................................................................................................................. 91 Stepwise approach to diagnosis of patients with respiratory symptoms ................................................................. 92 Future research.......................................................................................................................................................... 98 SECTION 2. CHILDREN 5 YEARS AND YOUNGER ............................................................................................................ 99

Chapter 6. Diagnosis and management of asthma in children 5 years and younger ................................................ 99 Part A. Diagnosis ......................................................................................................................................................... 100 Asthma and wheezing in young children ................................................................................................................. 100 Clinical diagnosis of asthma..................................................................................................................................... 101 Tests to assist in diagnosis ....................................................................................................................................... 103 Differential diagnosis ............................................................................................................................................... 104 Part B. Assessment and management........................................................................................................................ 106 Goals of asthma management................................................................................................................................. 106 Assessment of asthma ............................................................................................................................................. 106

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Medications for symptom control and risk reduction ............................................................................................. 108 Reviewing response and adjusting treatment ......................................................................................................... 113 Choice of inhaler device ........................................................................................................................................... 113 Asthma self-management education for carers of young children ......................................................................... 114 Part C. Management of worsening asthma and exacerbations in children 5 years and younger ........................... 115 Diagnosis of exacerbations ...................................................................................................................................... 115 Initial home management of asthma exacerbations ............................................................................................... 116 Primary care or hospital management of acute asthma exacerbations ................................................................. 118 Chapter 7. Primary prevention of asthma ............................................................................................................. 123 Factors contributing to the development of asthma .............................................................................................. 124 Factors associated with increased or DECREASED risk of asthma in children ......................................................... 124 Advice about primary prevention of asthma ........................................................................................................... 126 SECTION 3. TRANSLATION INTO CLINICAL PRACTICE .................................................................................................129

Chapter 8. Implementing asthma management strategies into health systems .................................................... 129 Introduction ............................................................................................................................................................. 130 Adapting and implementing asthma clinical practice guidelines ............................................................................ 130 Barriers and facilitators ........................................................................................................................................... 132 Examples of high impact implementation interventions ........................................................................................ 132 Evaluation of the implementation process.............................................................................................................. 132 How can GINA help with implementation? ............................................................................................................. 133 REFERENCES .................................................................................................................................................................... 134

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Tables and figures DIAGNOSIS Box 1-1. Box 1-2. Box 1-3. Box 1-4. Box 1-5.

Diagnostic flowchart for clinical practice – initial presentation ........................................................................... 16 Diagnostic criteria for asthma in adults, adolescents, and children 6–11 years ................................................ 17 Differential diagnosis of asthma in adults, adolescents and children 6–11 years ............................................. 20 Confirming the diagnosis of asthma in a patient already taking controller treatment ........................................ 22 How to step down controller treatment to help confirm the diagnosis of asthma .............................................. 23

ASSESSMENT Box 2-1. Box 2-2. Box 2-3. Box 2-4.

Assessment of asthma in adults, adolescents, and children 6–11 years .......................................................... 27 GINA assessment of asthma control in adults, adolescents and children 6–11 years...................................... 29 Specific questions for assessment of asthma in children 6–11 years ............................................................... 30 Investigating a patient with poor symptom control and/or exacerbations despite treatment ............................. 34

MANAGEMENT Box 3-1. Box 3-2. Box 3-3. Box 3-4. Box 3-5. Box 3-6. Box 3-7. Box 3-8. Box 3-9. Box 3-10. Box 3-11. Box 3-12. Box 3-13. Box 3-14.

Communication strategies for health care providers ......................................................................................... 37 The control-based asthma management cycle.................................................................................................. 38 Population level versus patient level decisions about asthma treatment .......................................................... 40 Recommended options for initial controller treatment in adults and adolescents ............................................. 43 Stepwise approach to control symptoms and minimize future risk.................................................................... 44 Low, medium and high daily doses of inhaled corticosteroids .......................................................................... 45 Options for stepping down treatment once asthma is well controlled ............................................................... 50 Treating modifiable risk factors to reduce exacerbations .................................................................................. 51 Non-pharmacological interventions - summary ................................................................................................. 53 Indications for considering referral for expert advice, where available.............................................................. 56 Strategies to ensure effective use of inhaler devices ........................................................................................ 57 Poor medication adherence in asthma .............................................................................................................. 59 Asthma information ............................................................................................................................................ 60 Investigation and management of severe asthma............................................................................................. 72

EXACERBATIONS Box 4-1. Box 4-2. Box 4-3. Box 4-4. Box 4-5.

Factors that increase the risk of asthma-related death ..................................................................................... 75 Self-management of worsening asthma in adults and adolescents with a written asthma action plan............. 77 Management of asthma exacerbations in primary care (adults, adolescents, children 6–11 years)................. 80 Management of asthma exacerbations in acute care facility, e.g. emergency department .............................. 83 Discharge management after hospital or emergency department care for asthma .......................................... 88

ASTHMA-COPD OVERLAP Box 5-1. Box 5-2a. Box 5-2b. Box 5-3. Box 5-4. Box 5-5.

Current definitions of asthma and COPD, and clinical description of asthma-COPD overlap .......................... 92 Usual features of asthma, COPD and asthma-COPD overlap .......................................................................... 94 Features that if present favor asthma or COPD ................................................................................................ 94 Spirometric measures in asthma, COPD and asthma-COPD overlap .............................................................. 95 Summary of syndromic approach to diseases of chronic airflow limitation for clinical practice ........................ 97 Specialized investigations sometimes used in distinguishing asthma and COPD ............................................ 98

CHILDREN 5 YEARS AND YOUNGER Box 6-1. Box 6-2. Box 6-3. Box 6-4. Box 6-5. Box 6-6. Box 6-7. Box 6-8.

Probability of asthma diagnosis or response to asthma treatment in children 5 years and younger .............. 101 Features suggesting a diagnosis of asthma in children 5 years and younger................................................. 102 Common differential diagnoses of asthma in children 5 years and younger ................................................... 105 GINA assessment of asthma control in children 5 years and younger............................................................ 107 Stepwise approach to long-term management of asthma in children 5 years and younger ........................... 111 Low daily doses of inhaled corticosteroids for children 5 years and younger ................................................. 112 Choosing an inhaler device for children 5 years and younger ........................................................................ 114 Primary care management of acute asthma or wheezing in children 5 years and younger............................ 117

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Box 6-9. Box 6-10. Box 6-11.

Initial assessment of acute asthma exacerbations in children ...