The document summarizes guidelines from the Global Initiative for Asthma (GINA) from 2002, 2006, and 2007. The key changes between the guidelines were a shift from classifying asthma severity based on clinical features to classifying control based on impairment. The 2002 guidelines emphasized classifying patients by severity determined by symptoms, lung function, and medication use. The 2006-2007 guidelines emphasized classifying asthma based on level of control determined by impairment and risk of exacerbations. Both guidelines provided recommendations for diagnosis, treatment including medications, and management of exacerbations.

1. Global Initiative for Asthma Management 2009: Please visit: http://crisbertcualteros.page.tl

9. GINA ASTHMA GUIDELINES 2002, 2006, 2007 DIAGNOSIS: Reversibility of measurements of lung function enhances confidence in making a diagnosis of asthma Often prompted by symptoms: episodic breathlessness wheezing cough chest tightness Assessment of the severity of airflow limitation Reversibility and variability confirms the Diagnosis of asthma Asthma severity: Amount of daily medications required for optimal treatment Asthma severity is measured NOT by severity of the underlying disease BUT its responsiveness to treatment 2002 2006 - 07 Measurement of allergic state helps to identify Risk factors that causes asthma symptoms in patients

17. GINA ASTHMA GUIDELINES: Diagnosis and Classification 2002 Classification of Asthma Severity by Clinical Features Before Treatment Intermittent: Mild Moderate Severe Persistent: Persistent: Persistent: Symptoms less than once a week Brief exacerbations Nocturnal symptoms NOT more than twice a month FEV 1 or PEF≥80% Predicted PEF or FEV 1 variability 20-30% Symptoms more Than once a week But less than once A day Exacerbations may Affect activity and Sleep Nocturnal symptoms More than twice a Month FEV 1 or PEF≥ 80% Predicted PEF or FEV 1 variability 20-30% Symptoms daily Exacerbations may Affect activity and sleep Nocturnal symptoms more than once a week Daily use of inhaled short acting β 2 -agonist FEV 1 or PEF 60-80% Predicted PEF or FEV 1 variability>30% Symptoms daily Frequent exacerbations Frequent Nocturnal asthma symptoms Limitation of physical activities FEV 1 or PEF ≤60% Predicted PEF or FEV 1 Variability > 30%

18. Classify Asthma Based on Severity: Severity INTERMITTENT PERSISTENT Mild Moderate Severe Daytime Symptoms < 1x a week  1x/wk Daily Daily Affects daily Limits daily activities activities Nighttime Symptoms  2x/month >2x/month >1x/week Frequent PEF  80%  80% >60-<79% <60% predicted predicted predicted predicted PEF Variability  20% 20-30% >30% >30% variability variability variability variability FEV1  80%  80% 60-79% <60% (GINA 2002)

19. GINA ASTHMA GUIDELINES: 2006 Levels of Asthma Control Characteristic Controlled(All of the ff) Partly Controlled (Any measure present in any week) Uncontrolled Daytime symptoms None (2x or </wk.) More than 2x/wk Three or more features of partly controlled asthma present in any week Limitations of activities None Any Nocturnal symptoms/ awakening None Any Need for reliever/rescue tx None (2x or less/week) More than 2x/ wk Lung function (PEF or FEV1) + Normal <80% predicted or personal best (if known) Exacerbations None One or more/ yr* One in any wk ╪

20. Asthma in Acute Exacerbation GINA ASTHMA GUIDELINES: 2002 2006-07

21. Severity of Asthma Exacerbations….. MILD MODERATE SEVERE RESPIRATORY ARREST IMMINENT Breathless Walking Talking At rest Infants – softer Infants- Stops shorter cry feeding Can lie flat Prefers sitting *Hunched forward Talks in Sentences Phrases Words Alertness May be agitated Usually agitated Usually agitated Respiratory Rate Increased Increased *Often >30/min Bradypnea GUIDE TO RATES OF BREATHING ASSOCIATED WITH RESPIRATORY DISTRESS IN AWAKE CHILDREN AGE NORMAL RATE > 2 months < 60/min 2-12 months < 50/min 1-5 years < 40/min 6-8 years < 30/min GINA 2002, 2006, 2007

22. MILD MODERATE SEVERE RESPIRATORY ARREST IMMINENT Accessory None Present Present Present Muscles & Thoraco-abdominal Suprasternal Movement Retraction Wheeze Audible with Audible with Audible w/o Absence of wheeze stethoscope stethoscope stethoscope with decreased to absent breathe sounds Pulses/min <100 100-120 >120 Bradycardia GUIDE TO LIMITS OF NORMAL PULSE RATE IN CHILDREN Age Normal Limits Infants 2-12 months <160/min Preschool 1-2 years <120/min School Age 2-6 years <110/min Severity of Asthma Exacerbations….. GINA 2002, 2006, 2007

23. Severity of Asthma Exacerbations MILD MODERATE SEVERE RESPIRATORY ARREST IMMINENT Pulses Paradoxus Absent May be present Often present Absence suggests <10mm Hg 10—20mm Hg 20-40mm Hg respiratory muscle fatigue PEF  80% 60-79% <60% %predicted Or %personal best PaO2 RA Normal  60mm Hg <60mmHg test NOT usually Possible Cyanosis necessary PaCO2  45 mm Hg  45 mm Hg >45 mm Hg possible respiratory failure SaO2 RA  95% 90-94% <90% Hypercapnea (hypoventilation) develops more rapidly in young children GINA 2002,2006,2007

32. GINA 2006, 2007 maintain and find lowest controlling step consider stepping up to gain control step up until controlled treat as exacerbation TREATMENT OF ACTION controlled partly controlled uncontrolled exacerbation LEVEL OF CONTROL INCREASE REDUCE

33. GINA 2006, 2007 CONTROLLER OPTIONS * Inhaled glucocorticosteroid ** receptor antagonist or synthesis inhibitors asthma education environmental control as needed rapid acting β 2- agonist as needed rapid acting β 2- agonist SELECT ONE SELECT ONE ADD ONE OR MORE ADD ONE OR BOTH low-dose ICS* low-dose ICS plus LABA Medium- or high-dose ICS plus LABA Oral gluco-corticosteroid leukotriene modifier** Medium- or high-dose ICS leukotriene modifier Anti-IgE treatment low-dose ICS plus leukotriene modifier sustained- release theophylline low-dose ICS plus leukotriene modifier

34. Inhaled Corticosteroids: Cornerstone in the Management Of Asthma GINA ASTHMA GUIDELINES 2002, 2006-07

41. Maintenance Therapy: GINA ASTHMA GUIDELINES 2002, 2006, 2007 2002 2006 2007 IGCS + LABA Not mentioned As form of therapy Not recommended For children ≤ 5 years As maintenance and rescue Medication has shown to reduce exacerbations in children ≥ 4 years with moderate & severe asthma

42. Estimated Equipotent Daily Doses of Inhaled Corticosteroids for Children Drug Low Daily Dose Medium Daily Dose High Daily Dose (µg) (µg) (µg) Beclomethasone 100 – 200 >200 – 400 >400 Dipropionate Budesonide 100-200 >200- 400 >400 Ciclesonide 80-160 >160-320 >320 Flunisolide 500-750 > 750-1250 > 1250 Fluticasone 100-200 > 200 – 500 >500 Mometasone 100-200 >200 – 500 >400 furoate Triamcinolone 400-800 >800 – 1200 > 1200 acetonide GINA ASTHMA GUIDELINES 2002,2006-07

43. Choosing an Inhaler Device for Children with Asthma Age Group Preferred device Alternate Device Younger than 4 years Pressurized metered Nebulizer with face dose inhaler plus mask dedicated spacer with face mask 4 – 6 years Pressurized metered Nebulizer with dose inhaler plus mouth piece dedicated spacer with mouth piece Older than 6 years Dry powder inhaler, Nebulizer with mouth or breath-actuated piece pressurized metered- dose inhaler or pressurized metered dose inhaler with spacer mouth piece

44. Leukotriene Pathway

48. Montelukast+Budesonide vs. Double Dose of Budesonide Price, D.B. et. Al., Thorax 2003; 58: 211-216

49. Montelukast vs. Corticosteroid based on Quality of Life Price, D.B. et. Al., Thorax 2003; 58: 211-216