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GLOBAL INITIATIVE
FOR ASTHMA
PREFACE .......................................................................................2
1
PREFACE
Asthma is a major cause of chronic morbidity and mortality throughout the
world and there is evidence that its prevalence has increased considerably
over the past 20 years, especially in children. The Global Initiative for
Asthma was created to increase awareness of asthma among health pro-
fessionals, public health authorities, and the general public, and to improve
prevention and management through a concerted worldwide effort. The
Initiative prepares reports on asthma management based on the best avail-
able scientific evidence, encourages dissemination and implementation of
the recommendations, and promotes international collaboration on asthma
research.
2
WHAT IS KNOWN
ABOUT ASTHMA?
Unfortunately… asthma is the most common chronic disease of child-
hood and the leading cause of childhood morbidity from chronic disease
as measured by absence from day care, emergency department visits, and
hospitalizations. There are special challenges that must be taken into
account in managing asthma in children during the first 5 years of life.
3
DIAGNOSING ASTHMA
Making a definite diagnosis of asthma in children 5 years and younger is
challenging because episodic respiratory symptoms such as wheezing and
cough are also common in children who do not have asthma, particularly in
those younger than 3 years. Not all young children who wheeze have asth-
ma, and the younger the child, the greater the likelihood that an alterna-
tive diagnosis may explain recurrent wheeze. These alternatives must be
considered and excluded before an asthma diagnosis is made.
Alternative causes of recurrent wheezing, particularly in early infancy,
include infections (recurrent viral lower respiratory tract infections, chronic
rhino-sinusitis, tuberculosis); congenital problems (cystic fibrosis, bronchopul-
monary dysplasia, congenital malformation causing narrowing of the
intrathoracic airways, primary ciliary dyskinesia syndrome, immune deficien-
cy, and congenital heart disease) and mechanical problems (foreign body
aspiration).
A difficulty with diagnosing asthma in children 5 years and younger is that
the lung function measurements that are key to diagnosis in older children
and adults are not reliable in this age group.
A trial of treatment with short-acting bronchodilators and inhaled glucocorti-
costeroids can help confirm an asthma diagnosis: look for marked clinical
improvement during the treatment and deterioration when treatment is
stopped. The presence of atopy or allergic sensitization also increases the
likelihood that a wheezing child will have asthma.
Taking all of these factors into account, a diagnosis of asthma in these young
children can often be made based largely on symptom patterns and on a
careful clinical assessment of family history and physical findings (Table 1).
Table 1. Is It Asthma?
Consider asthma if any of the following signs or symptoms are present:
n Frequent episodes of wheezing—more than once a month.
n Activity-induced cough or wheeze.
n Cough particularly at night during periods without viral infections.
n Absence of seasonal variation in wheeze.
n Symptoms that persist after age 3.
n Symptoms occur or worsen in the presence of:
• Aeroallergens (house dust mites, companion animals, cockroach, fungi)
• Exercise
• Pollen
• Respiratory (viral) infections
• Strong emotional expression
• Tobacco smoke
n The child’s colds repeatedly “go to the chest” or take more than 10 days to clear up.
n Symptoms improve when asthma medication is given.
4
CLASSIFICATION OF ASTHMA
BY LEVEL OF CONTROL
For all patients with a confirmed diagnosis of asthma, the goal of treatment
is to achieve and maintain control of the disease. However, assessing
asthma control in children 5 years and younger is difficult, because health
care providers are almost exclusively dependent on the reports of the
child’s family members and caregivers who might be unaware of the pres-
ence of asthma symptoms, or of the fact that they represent uncontrolled
asthma. Additional information about asthma control may be gleaned from
the child’s need for reliever/rescue treatment (with increased use indicating
worsening control).
5
MANAGEMENT AND
PHARMACOLOGIC TREATMENT
Control of asthma can be achieved in a majority of children 5 years and
younger with an intervention strategy that includes:
• A partnership between the child’s family/caregivers and the health care team
• Avoidance of risk factors
• A plan to assess, treat with appropriate pharmacologic therapy, and
monitor asthma control
• An action plan to enable the child’s family members and caregivers to
recognize an asthma attack and initiate treatment, recognize a severe
episode, and identify when urgent treatment at a hospital (health care
facility) is required.
Develop a Partnership –
Family/Caregivers and Health Care Providers
With the help of everyone on the health care team, families/caregivers can
be actively involved in managing asthma to prevent problems and enable
children to live productive, physically active lives. They can learn to:
• Help the child avoid risk factors
• Ensure that the child takes medications correctly
• Understand the difference between “controller” & “reliever” medications
• Monitor asthma control status using symptoms
• Recognize signs that asthma is worsening and take action
• Seek medical help as appropriate
6
Identify and Reduce Exposure to Risk Factors
To improve control of asthma and reduce medication needs, patients
should take steps to avoid the risk factors that cause their asthma symp-
toms (Table 3). However, many asthma patients react to multiple factors
that are ubiquitous in the environment, and avoiding some of these factors
completely is nearly impossible. Thus, medications to maintain asthma
control have an important role because patients are often less sensitive to
these risk factors when their asthma is under control.
• Drugs, foods, and additives: Avoid if they are known to cause symptoms.
• Animals with fur: Use air filters. (Remove animals from the home, or at least
from the sleeping area. Wash the pet.)
• Cockroaches: Clean the home thoroughly and often. Use pesticide spray—
but make sure the patient is not at home when spraying occurs.
• Outdoor pollens and mold: Close windows and doors and remain indoors
when pollen and mold counts are highest.
• Indoor mold: Reduce dampness in the home; clean any damp areas fre-
quently.
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ASSESS, TREAT, AND MONITOR ASTHMA
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Information about use of various inhaler devices is found on the GINA
Website (www.ginasthma.org).
If the child’s asthma is not controlled with as-needed use of reliever med-
ication, a low-dose inhaled glucocorticosteroid is the recommended initial
controller treatment (Table 4).
This initial treatment should be given for at least 3 months to establish its
effectiveness in reaching control. If at the end of this period the low dose
of inhaled glucocorticosteroid does not control symptoms, and the child is
using optimal technique and is adherent to therapy, doubling the initial
dose of glucocorticosteroid given in Table 5 may be the best option.
Addition of a leukotriene modifier to the low-dose inhaled glucocorticos-
teroid may also be considered.
9
Table 4. Asthma Management Approach Based on
Control for Children 5 Years and Younger
Asthma education, Environmental control, and As needed rapid-acting β 2-agonists
Controller options
*Oral glucocorticosteroids should be used only for treatment of acute severe exacerbations of asthma.
Shaded boxes represent preferred treatment options.
†
Ciclesonide NS
†
Mometasone furoate NS
†
Triamcinolone acetonide NS
* A low daily dose is defined as the dose which has not been associated with clinically adverse
effects in trials including measures of safety. This is not a table of clinical equivalence.
† NS = Not studied in this age group.
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Monitoring to Maintain Control
Ongoing monitoring is essential to maintain control and establish the low-
est step and dose of treatment to minimize cost and maximize safety.
Typically, patients should be seen one to three months after the initial visit,
and every three months thereafter. After an exacerbation, follow-up should
be offered within two weeks to one month.
Adjusting medication:
• If asthma is not controlled within one to three months by doubling the ini-
tial dose of inhaled glucocorticosteroids, assess and monitor the child’s
inhalation technique, compliance with medication regimen, and avoid-
ance of risk factors.
• If control is maintained for at least 3 months, decrease treatment to the
least medication necessary to maintain control. Monitoring is still neces-
sary even after control is achieved, as asthma is a variable disease;
treatment has to be adjusted periodically in response to loss of control as
indicated by worsening symptoms or the development of an exacerbation.
Home Management
A health care provider may recommend steps for the family/caregiver to
care for an asthma attack at home:
.
• Initiate treatment with two puffs of inhaled rapid-acting β 2-agonist,
given one puff at a time via a mask or spacer device.
• Observe the child and maintain a restful atmosphere for one hour or
more
• Seek medical attention the same day if inhaled bronchodilator is
required for symptom relief more than every 3 hours or for more than
24 hours.
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Table 6. Initial Assessment of Acute Asthma in Children
Five Years and Younger
Symptoms Mild Severea
Pulse rate < 100 bpmd > 200 bpm (0-3 years)
> 180 bpm (4-5 years)
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Table 7. Indications for Immediate Referral to Hospital
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Table 8: Initial Management of Acute
Severe Asthma in Children 5 Years and Younger*
Oral prednisolone
Systemic (1-2 mg/kg daily for up to 5 days)
glucocorticosteroids or
Intravenous methylprednisolone
1 mg/kg every 6 hours on day 1;
every 12 hours on day 2; then daily
Oral β 2-agonists No
Long-acting β 2-agonist No
a If inhalation is not possible an intravenous bolus of 5 µg/kg given over 5 minutes, followed by
continuous infusion of 5 µg/kg/hour.
The dose should be adjusted according to clinical effect and side effects84.
15
Follow up:
Before discharge from the emergency department or hospital, the condition
of the patient should be stable, e.g., out of bed and able to eat and drink
without problem. Family/caregivers should receive:
16
The Global Initiative for Asthma is supported by educational grants from: