GINA GUIDELINES 2013 PDF
GINA Report, Global Strategy for Asthma Management and Prevention and Prevention incorporates new scientific information about asthma based on a . Guidelines from around the world Wong GW et al. Allergy ; %. 44%. % GINA Asthma Treatment Strategy. ○ GINA Science. Medical Editor. Global Strategy for Asthma Management and Prevention i. * Disclosures for members of GINA Executive and Science Committees can be.
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The GINA reports are available on cittadelmonte.info Global Strategy for Asthma Management and Prevention (revision). GINA BOARD OF. The Global Initiative for Asthma (GINA) was established to increase awareness about extensively revised in to provide a comprehensive and integrated. At the same time, the Global Initiative for Asthma (GINA) was implemented to .. SUMMARY OF RECOMMENDATIONS IN THE UPDATE. A. Additions to.
They are prepared by international experts from primary, secondary and tertiary care, and are annually updated following a review of evidence. In , a major revision of the GINA report was published, that took into account advances in evidence not only about asthma and its treatment, but also about how to improve implementation of evidence-based recommendations in clinical practice. This paper summarises key changes relevant to primary care in the new GINA report. Key changes in recommendations include a new, diagnosis-centred definition of asthma; more detail about how to assess current symptom control and future risk; a comprehensive approach to tailoring treatment for individual patients; expanded indications for commencing inhaled corticosteroids; new recommendations for written asthma action plans; a new chapter on diagnosis and initial treatment of patients with asthma—COPD overlap syndrome; and a revised approach to diagnosing asthma in preschool children.
Asthma is a major burden worldwide, for governments, health-care providers, patients and their carers, 1 and there is considerable variation in asthma prevalence, morbidity and mortality.
The GINA report is not a guideline, but a global strategy that can be adapted to local conditions; over the years, the reports have provided the foundation for many national guidelines. The GINA strategy report, prepared by international experts from primary, secondary and tertiary care, is annually updated following a review of evidence, and is now independently funded by the sale of GINA documents and resources.
Over recent years, research has led to considerable advances not only in our knowledge about asthma and treatment options 4 but also in our understanding of how to implement evidence-based recommendations within clinical practice. This paper summarises the key changes in the GINA strategy report that are most relevant to health professionals working in primary care.
While retaining its solid evidence base, the GINA report was developed with the specific aim of improving utility for busy clinicians, with a user-friendly format, clear language and layout, and liberal use of practical summary tables and flow charts to assist with problems that clinicians face every day.
Background detail about physiology and pharmacology was moved to an Online Appendix.
GINA Reports - Global Initiative for Asthma - GINA
This clinical definition, focussing on the two key features needed for the diagnosis of asthma variable respiratory symptoms and variable airflow limitation , replaces a previous lengthy description of pathological and physiological features of asthma.
For the first time, asthma is also defined as a heterogeneous disease. Tools include tables summarising criteria for variable expiratory airflow limitation, prioritised by reliability and feasibility for clinical practice. Clinicians are strongly encouraged to document the basis for diagnosis of asthma in individual patients; this is invaluable if the patient fails to respond to treatment or the diagnosis is in doubt.
Specific advice is provided about confirming the diagnosis in special populations, e. Past asthma control assessments have focussed on current symptom control e. Poor symptom control itself is a well-known risk factor for exacerbations; GINA also includes an expanded list of other risk factors that are independent of the level of symptom control, including incorrect inhaler technique, poor adherence and low lung function.
A helpful table explains specific treatment for modifiable risk factors, as not all risk factors for exacerbations require a step-up in asthma treatment. As above, asthma control relates both to symptom control and risk factors for future adverse outcomes such as exacerbations, and it can be quickly assessed at any time; whereas asthma severity based on the level of treatment required to achieve good control is a label that can only be applied retrospectively after the patient has been on treatment for at least several months.
Patients whose asthma remains uncontrolled despite appropriate management should be referred promptly for specialist investigation and advice.
In the past, this concept was sometimes interpreted as prompting an automatic step-up in controller treatment if symptoms were not well controlled. Key changes for primary care in the GINA report emphasise that control-based management should include three components:. Tables with evidence levels are provided in the report. The GINA report now includes a new table with evidence-based recommendations for initiating controller treatment.
The GINA report now describes a framework for personalised asthma management. Past guidelines for asthma and COPD have been separate, and most regulatory studies have excluded patients with both conditions. However, many patients have features of both asthma and COPD, including symptomatic smokers with a history of childhood asthma, and patients with asthma and fixed airflow limitation.
The GINA report now includes several new tools: Every patient should have an individualised written asthma action plan. The aim is to reduce the risk of future severe exacerbations, even if symptoms are currently well controlled, and to minimise the impact of uncontrolled asthma on schooling and physical and social development. Additional implementation tools, reflecting the recommendations in the GINA report, will be added during Annual updates to the GINA report will be published based on a review of recent evidence.
The new GINA strategy report and supporting resources provide a substantial array of new, practical, evidence-based materials that supplement current national asthma guidelines, or can be adapted for local use, in both high- and low-resource countries.
The aim is to reduce the burden of asthma, both for patients who suffer from this disease and for health-care systems. Years lived with disability YLDs for sequelae of diseases and injuries Lancet ; European Respiratory Society The European lung white book.
Global and regional mortality from causes of death for 20 age groups in and The revised GINA strategy report: Curr Opin Pulm Med ; Eur Respir J ; Global Initiative for Asthma.
The GINA asthma strategy report: what’s new for primary care?
Global strategy for asthma management and prevention. Updated Global strategy for asthma management and prevention: Clinical implications of the Royal College of Physicians three questions in routine asthma care: Prim Care Respir J ; Development of the Asthma Control Test: J Allergy Clin Immunol ; Development and validation of a questionnaire to measure asthma control. Severe asthma in adults: User error with Diskus and Turbuhaler by asthma patients and pharmacists in Jordan and Australia.
Respir Care ; Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists. Overdiagnosis of asthma in obese and nonobese adults. CMAJ ; Overtreatment with inhaled corticosteroids and diagnostic problems in primary care patients, an exploratory study.
Fam Pract ; How often is the diagnosis bronchial asthma correct? Accuracy of a first diagnosis of asthma in primary health care. The hygiene hypothesis attempts to explain the increased rates of asthma worldwide as a direct and unintended result of reduced exposure, during childhood, to non-pathogenic bacteria and viruses.
Use of antibiotics in early life has been linked to the development of asthma. Family history is a risk factor for asthma, with many different genes being implicated. Even among this list of genes supported by highly replicated studies, results have not been consistent among all populations tested.
Some genetic variants may only cause asthma when they are combined with specific environmental exposures. Endotoxin exposure can come from several environmental sources including tobacco smoke, dogs, and farms. Risk for asthma, then, is determined by both a person's genetics and the level of endotoxin exposure.
A triad of atopic eczema , allergic rhinitis and asthma is called atopy. There is a correlation between obesity and the risk of asthma with both having increased in recent years. Beta blocker medications such as propranolol can trigger asthma in those who are susceptible. Some individuals will have stable asthma for weeks or months and then suddenly develop an episode of acute asthma.
Different individuals react to various factors in different ways. Home factors that can lead to exacerbation of asthma include dust , animal dander especially cat and dog hair , cockroach allergens and mold. Both viral and bacterial infections of the upper respiratory tract can worsen the disease.
Asthma is the result of chronic inflammation of the conducting zone of the airways most especially the bronchi and bronchioles , which subsequently results in increased contractability of the surrounding smooth muscles. This among other factors leads to bouts of narrowing of the airway and the classic symptoms of wheezing.
The narrowing is typically reversible with or without treatment. Occasionally the airways themselves change. Chronically the airways' smooth muscle may increase in size along with an increase in the numbers of mucous glands.
Other cell types involved include: T lymphocytes , macrophages , and neutrophils. There may also be involvement of other components of the immune system including: Figure A shows the location of the lungs and airways in the body. Figure B shows a cross-section of a normal airway. Figure C shows a cross-section of an airway during asthma symptoms. Obstruction of the lumen of a bronchiole by mucoid exudate, goblet cell metaplasia , and epithelial basement membrane thickening in a person with asthma.
While asthma is a well-recognized condition, there is not one universal agreed upon definition. The chronic inflammation is associated with airway hyper-responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing particularly at night or in the early morning. These episodes are usually associated with widespread but variable airflow obstruction within the lung that is often reversible either spontaneously or with treatment".
There is currently no precise test for the diagnosis, which is typically based on the pattern of symptoms and response to therapy over time. Spirometry is recommended to aid in diagnosis and management. It however may be normal in those with a history of mild asthma, not currently acting up.
The methacholine challenge involves the inhalation of increasing concentrations of a substance that causes airway narrowing in those predisposed. If negative it means that a person does not have asthma; if positive, however, it is not specific for the disease.
Other supportive evidence includes: It may be useful for daily self-monitoring in those with moderate to severe disease and for checking the effectiveness of new medications.
It may also be helpful in guiding treatment in those with acute exacerbations. Asthma is clinically classified according to the frequency of symptoms, forced expiratory volume in one second FEV 1 , and peak expiratory flow rate.
Although asthma is a chronic obstructive condition, it is not considered as a part of chronic obstructive pulmonary disease , as this term refers specifically to combinations of disease that are irreversible such as bronchiectasis , chronic bronchitis , and emphysema. An acute asthma exacerbation is commonly referred to as an asthma attack. The classic symptoms are shortness of breath , wheezing , and chest tightness.
Signs occurring during an asthma attack include the use of accessory muscles of respiration sternocleidomastoid and scalene muscles of the neck , there may be a paradoxical pulse a pulse that is weaker during inhalation and stronger during exhalation , and over-inflation of the chest. Acute severe asthma , previously known as status asthmaticus, is an acute exacerbation of asthma that does not respond to standard treatments of bronchodilators and corticosteroids.
Brittle asthma is a kind of asthma distinguishable by recurrent, severe attacks. Type 2 brittle asthma is background well-controlled asthma with sudden severe exacerbations.
Exercise can trigger bronchoconstriction both in people with or without asthma. Asthma as a result of or worsened by workplace exposures is a commonly reported occupational disease. A few hundred different agents have been implicated, with the most common being: The employment associated with the highest risk of problems include: Alcohol may worsen asthmatic symptoms in up to a third of people.
There is negative skin test to common inhalant allergens and normal serum concentrations of IgE. Often it starts later in life, and women are more commonly affected than men. Usual treatments may not work as well. Many other conditions can cause symptoms similar to those of asthma. In children, other upper airway diseases such as allergic rhinitis and sinusitis should be considered as well as other causes of airway obstruction including foreign body aspiration , tracheal stenosis , laryngotracheomalacia , vascular rings , enlarged lymph nodes or neck masses.
In both populations vocal cord dysfunction may present similarly. Chronic obstructive pulmonary disease can coexist with asthma and can occur as a complication of chronic asthma. After the age of 65, most people with obstructive airway disease will have asthma and COPD. In this setting, COPD can be differentiated by increased airway neutrophils, abnormally increased wall thickness, and increased smooth muscle in the bronchi.
However, this level of investigation is not performed due to COPD and asthma sharing similar principles of management: The evidence for the effectiveness of measures to prevent the development of asthma is weak. Early pet exposure may be useful. Dietary restrictions during pregnancy or when breast feeding have not been found to be effective and thus are not recommended.
While there is no cure for asthma, symptoms can typically be improved. This plan should include the reduction of exposure to allergens, testing to assess the severity of symptoms, and the usage of medications. The treatment plan should be written down and advise adjustments to treatment according to changes in symptoms. The most effective treatment for asthma is identifying triggers, such as cigarette smoke , pets, or aspirin , and eliminating exposure to them.
If trigger avoidance is insufficient, the use of medication is recommended. Pharmaceutical drugs are selected based on, among other things, the severity of illness and the frequency of symptoms. Specific medications for asthma are broadly classified into fast-acting and long-acting categories. Bronchodilators are recommended for short-term relief of symptoms. In those with occasional attacks, no other medication is needed.
If mild persistent disease is present more than two attacks a week , low-dose inhaled corticosteroids or alternatively, a leukotriene antagonist or a mast cell stabilizer by mouth is recommended. For those who have daily attacks, a higher dose of inhaled corticosteroids is used.
In a moderate or severe exacerbation, corticosteroids by mouth are added to these treatments. People with asthma have higher rates of anxiety and depression. Avoidance of triggers is a key component of improving control and preventing attacks. The most common triggers include allergens , smoke from tobacco or other sources , air pollution, non selective beta-blockers , and sulfite-containing foods. Medications used to treat asthma are divided into two general classes: Medications are typically provided as metered-dose inhalers MDIs in combination with an asthma spacer or as a dry powder inhaler.
The spacer is a plastic cylinder that mixes the medication with air, making it easier to receive a full dose of the drug. A nebulizer may also be used. Nebulizers and spacers are equally effective in those with mild to moderate symptoms. However, insufficient evidence is available to determine whether a difference exists in those with severe disease. Long-term use of inhaled corticosteroids at conventional doses carries a minor risk of adverse effects.
When asthma is unresponsive to usual medications, other options are available for both emergency management and prevention of flareups. For emergency management other options include:.
Evidence is insufficient to support the usage of vitamin C. Acupuncture is not recommended for the treatment as there is insufficient evidence to support its use. Manual therapies, including osteopathic , chiropractic , physiotherapeutic and respiratory therapeutic maneuvers, have insufficient evidence to support their use in treating asthma. The prognosis for asthma is generally good, especially for children with mild disease.
Globally it causes moderate or severe disability in As of , — million people worldwide are affected by asthma,    and approximately ,—, people die per year from the disease. While asthma is twice as common in boys as girls,  severe asthma occurs at equal rates. Global rates of asthma have increased significantly between the s and   with it being recognized as a major public health problem since the s. Asthma was recognized in ancient Egypt and was treated by drinking an incense mixture known as kyphi.
In , one of the first papers in modern medicine on the subject tried to explain the pathophysiology of the disease while one in , concluded that asthma can be cured by rubbing the chest with chloroform liniment. Bosworth theorized a connection between asthma and hay fever.
A notable and well-documented case in the 19th century was that of young Theodore Roosevelt — At that time there was no effective treatment.
Roosevelt's youth was in large part shaped by his poor health partly related to his asthma. He experienced recurring nighttime asthma attacks that caused the experience of being smothered to death, terrifying the boy and his parents. During the s to s, asthma was known as one of the "holy seven" psychosomatic illnesses.
Its cause was considered to be psychological, with treatment often based on psychoanalysis and other talking cures. From Wikipedia, the free encyclopedia. For other uses, see Asthma disambiguation. The sound of wheezing as heard with a stethoscope. See also: Asthma-related microbes.
Main article: Pathophysiology of asthma. Exercise-induced bronchoconstriction. Occupational asthma. Aspirin-exacerbated respiratory disease. Alcohol-induced respiratory reactions. Epidemiology of asthma. November Archived from the original on June 29, Retrieved 3 March European Respiratory Journal. February Allergy Clin. September Primary Care Respiratory Journal. Archived PDF from the original on Robbins and Cotran pathologic basis of disease 8th ed. Care Med. CS1 maint: Systematic review of epidemiological studies".
Sacred luxuries: Cornell University Press. In Mason, Robert J. Courtney; Nadel, Jay A. Murray and Nadel's textbook of respiratory medicine 5th ed. Textbook of pulmonary and critical care medicine. New Delhi: Jaypee Brothers Medical Publishers. Archived from the original on Extra text: Chest medicine: April June Expert Review of Respiratory Medicine.
Asthma, health and society a public health perspective. New York: Primary Care Respiratory Journal: Journal of the General Practice Airways Group.
Thomsen, Judith A. Contrast media: Proc Am Thorac Soc. Reproductive Toxicology Elmsford, N. Clinical and Experimental Allergy. Annu Rev Public Health. Environmental Health Perspectives.
Community Characteristics and Exposure to Air Toxics". Journal of Environmental Economics and Management. July Environ Health Perspect. International Journal of Andrology. European Respiratory Review. Paediatric Respiratory Reviews.
European Journal of Clinical Pharmacology. Archives of Disease in Childhood. The European Respiratory Journal. Current Opinion in Allergy and Clinical Immunology.
Current Allergy and Asthma Reports. Journal of Investigational Allergology and Clinical Immunology. Cochrane Database of Systematic Reviews 2: What do we really know? Journal of Allergy and Clinical Immunology. Current Opinion in Pulmonary Medicine.
May Immunology and Allergy Clinics of North America. Clinics in Perinatology.
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