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At-A-Glance Asthma

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Management Reference

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Updated 2011
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Please refer to the

Global Strategy for Asthma Management and Prevention
(updated 2011) - www.ginasthma.org

© Global Initiative for Asthma

 DIAGNOSING ASTHMA

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Asthma can often be diagnosed on the basis of a patient's symptoms and medical
history (e.g., see below).

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Questions to Consider in the Diagnosis of Asthma

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• Has the patient had an attack or recurrent attacks of wheezing?

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• Does the patient have a troublesome cough at night?
• Does the patient wheeze or cough after exercise?

OR
• Does the patient experience wheezing, chest tightness, or cough after
exposure to airborne allergens or pollutants?

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• Do the patient's colds "go to the chest" or take more than 10 days to clear up?
• Are symptoms improved by appropriate asthma treatment?

LT
TA
Measurements of lung function provide an assessment of the severity, reversibillity,
and variability of airflow limitation, and help confirm the diagnosis of asthma.
NO

Spirometry is the preferred method of measuring airflow limitation and its

reversibility to establish a diagnosis of asthma.
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• An increase in FEV1 of ≥ 12% and 200 ml after administration of a

bronchodilator indicates reversible airflow limitation consistent with asthma.
(However, most asthma patients will not exhibit reversibility at each
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assessment, and repeated testing is advised.)

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Peak expiratory flow (PEF) measurements can be an important aid in both

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diagnosis and monitoring of asthma.

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• PEF measurements are ideally compared to the patient's own previous best
measurements using his/her own peak flow meter.
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• An improvement of 60 L/min (or ≥ 20% of the pre-bronchodilator PEF) after

inhalation of a bronchodilator, or diurnal variation in PEF of more than 20%
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(with twice-daily readings, more than 10%) suggests a diagnosis of asthma.

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Additional diagnostic tests:

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• For patients with symptoms consistent with asthma, but normal lung function,
measurements of airway responsiveness to methacholine, histamine, direct
airway challenges such as inhaled mannitol, or exercise challenge may help
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establish a diagnosis of asthma.

• Skin tests with allergens or measurement of specific IgE in serum: The
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presence of allergies increases the probability of a diagnosis of asthma,

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and can help to identify risk factors that cause asthma symptomsin individual
patients.
 ASSESSING ASTHMA CONTROL

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Each patient should be assessed to establish his or her current treatment regimen,
adherence to the current regimen, and level of asthma control. A simplified

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scheme for recognizing controlled, partly controlled and uncontrolled asthma in a
given week is provided in the following figure.

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Levels of Asthma Control

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A. Assessment of current clinical control (preferably over 4 weeks)

OR
Characteristics Controlled Partly Controlled Uncontrolled
(All of the following) (Any measure presented)
Daytime symptoms None (twice or less/week) More than twice/week Three or more features of

ER
partly controlled asthma*†
Limitation of activities None Any

LT
Nocturnal None Any
symptoms/awaking
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Need for reliever/ None (twice or less/week) More than twice/week
rescue inhaler
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Lung function (PEF or FEV1)‡ Normal < 80% predicted or

personal best (if known)
B. Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side effects)
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Features that are associated with increased risk of adverse events in the future include:
Poor clinical control, frequent exacerbations in past year*, ever admission to critical care for asthma, low FEV1, exposure to
cigarette smoke, high dose medications
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* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate
† By definition, an exacerbation in any week makes that an uncontrolled asthma week
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‡ Without administration of bronchodilator, lung function is not a reliable test for children 5 years and younger.
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TREATING TO ACHIEVE CONTROL

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The patient's current level of asthma control and current treatment determine the
selection of pharmacologic treatment. For example, if asthma is not controlled
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on the current treatment regimen, treatment should be stepped up until control

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is achieved. If control has been maintained for at least three months, treatment
can be stepped down with the aim of establishing the lowest step and dose of
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treatment that maintains control.

Asthma control should be monitored by the health care professional and preferably
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also by the patient at regular intervals. The frequency of health care visits and
assessments depends upon the patient's initial clinical severity and the patient's
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training and confidence in playing a role in the ongoing control of his or her
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asthma. Typically, patients are seen one to three months after the initial visit, and
every three months thereafter. After an exacerbation, follow-up should be offered
within two months to one month. The approach presented in the figure shown on
the following page is based on these principals.
 MANAGEMENT APPROACH
BASED ON CONTROL

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Management Approach Based on Control - Children Older than 5 Years, Adolescents and Adults

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Reduce
Level of Control Treatment Action

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Controlled Maintain and find lowest controlling step

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Partly controlled Consider stepping up to gain control

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Uncontrolled Step up until controlled

Increase
Exacerbation Treat as exacerbation

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Treatment Steps
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Reduce Increase
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Step 1 Step 2 Step 3 Step 4 Step 5
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Asthma education. Environmental control.

(If step-up treatment is being considered for poor symptom control, first check inhaler technique, check adherence, and confirm symptoms are due to asthma.)

As needed rapid-
As needed rapid-acting β2-agonist
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acting β2-agonist

To Step 3 treatment, To Step 4 treatment,

Select one Select one select one or more add either
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Medium-or high-dose
Low-dose inhaled Low-dose ICS plus Oral glucocorticosteroid
ICS plus long-acting
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ICS* long-acting β2-agonist

β2-agonist (lowest dose)

Controller
options*** Leukotriene Medium-or
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Leukotriene Anti-IgE
modifier** high-dose ICS modifier treatment
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Low-dose ICS plus Sustained release

leukotriene modifier theophylline
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Low-dose ICS plus

sustained release
theophylline
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*ICS = inhaled glucocorticosteroids

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**=Receptor antagonist or synthesis inhibitors

***=Recommneded treatment (shaded boxes) based on group mean data. Individual patient needs, preferences, and cirumstances (including costs) should
be considered.
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Alternative reliever treatments include inhaled anticholinergics, short-acting oral β2-agonists, some long-acting β2-agonists, and short-acting theophylline.
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Regular dosing with short and long-acting β2-agonists is not advised unless accompanied by regular use of an inhaled glucocorticorsteriod.
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For management of asthma in children 5 years and younger, refer to the Global Strategy for the Diagnosis and Management
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of Asthma in Children 5 Years and Younger, available at http://www.ginasthma.org.

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The Global Initiative for Asthma is supported by unrestricted educational grants from:
Almirall, AstraZeneca, Boehringer Ingelheim, Chiesi Group,
CIPLA, GlaxoSmithKline, Novartis, and Nycomed.