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GLOBAL STRATEGY FOR

ASTHMA MANAGEMENT AND PREVENTION

Updated 2015

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Global Strategy for Asthma Management and Prevention

The GINA reports are available on www.ginasthma.org.

Global Strategy for Asthma Management and Prevention (2015 update)

GINA BOARD OF DIRECTORS*		GINA SCIENCE COMMITTEE*			GINA PROGRAM
J. Mark FitzGerald, MD, Chair		Helen K. Reddel, MBBS PhD, Chair			Suzanne Hurd, PhD
University of British Columbia		Woolcock Institute of Medical Research			Scientific Director
Vancouver, BC, Canada		Sydney, Australia			GRAPHICS ASSISTANCE
Eric D. Bateman, MD		Eric D. Bateman, MD			GRAPHICS ASSISTANCE
Eric D. Bateman, MD		Eric D. Bateman, MD
University of Cape Town Lung Institute		University of Cape Town Lung Institute			Kate Chisnall
Cape Town, South Africa.		Cape Town, South Africa.			OR	REPRODUCE
Louis-Philippe Boulet, MD		Allan Becker, MD
Université Laval		University of Manitoba
Québec, QC, Canada		Winnipeg, MB, CANADA
Alvaro A. Cruz, MD		Johan C. de Jongste, MD PhD
Federal University of Bahia		Erasmus University Medical Center
Salvador, BA, Brazil		Rotterdam, The Netherlands
Tari Haahtela, MD		Jeffrey M. Drazen, MD (to Dec 2014)
Helsinki University Central Hospital		Harvard Medical School		ALTER
Helsinki, Finland		Boston, MA, USA

Mark L. Levy, MD		J. Mark FitzGerald, MD
The University of Edinburgh		University of British Columbia
Edinburgh, UK		Vancouver, BC, Canada
Paul O'Byrne, MD		Hiromasa Inoue, MD NOT
McMaster University		Kagoshima University
Hamilton, ON, Canada		Kagoshima, Japan
Pierluigi Paggiaro, MD		Robert F. Lemanske,DO	Jr., MD
University of Pisa		University-of Wisconsin
Pisa, Italy		Madison, WI, USA
Soren Erik Pedersen, MD		Paul O'Byrne, MD
Kolding Hospital		McMaster University
Kolding, Denmark		Hamilton, ON, Canada
Manuel Soto-Quiroz, MD		Soren Erik Pedersen, MD
Hospital Nacional de Niños		Kolding Hospital
San José, Costa Rica		Kolding, Denmark
Helen K. Reddel, MBBS PhD		Emilio Pizzichini, MD
Woolcock Institute of Medical Research		Universidade Federal de Santa Catarina
Sydney, Australia	MATERIALFlorianópolis, SC, Brazil
Gary W. Wong, MD		Stanley J. Szefler, MD
Chinese University of Hong Kong		Children's Hospital Colorado
Hong Kong, ROC		Aurora, CO, USA
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* Disclosures for members of GINA Board of Directors and Science Committee can be found at www.ginasthma.com

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Asthma is a serious global health problem affecting all age groups. Its prevalence is increasing in many countries,

Preface REPRODUCE

especially among children. Although some countries have seen a decline in hospitalizations and deaths from asthma,

asthma still imposes an unacceptable burden on health care systems, and on society through loss of productivity in the workplace and, especially for pediatric asthma, disruption to the family.

In 1993, the National Heart, Lung, and Blood Institute collaborated with the World Health Organization to convene a

workshop that led to a Workshop Report: Global Strategy for Asthma Management and Prevention.1 This was followed by

the establishment of the Global Initiative for Asthma (GINA), a network of individuals, organizations, and public health

officials to disseminate information about the care of patients with asthma, and to provide a mechanism to translate

scientific evidence into improved asthma care. The GINA Assembly was subsequently initiated, as an ad hoc group of Directors and the Dissemination and Implementation Committee to promote internationalORcollaboration and dissemination

dedicated asthma care experts from many countries. The Assembly works with the Science Committee, the Board of

of information about asthma. The GINA report (“Global Strategy for Asthma Management and Prevention”), has been

2001, GINA initiated an annual World Asthma Day, raising awareness about the burden of asthma, and becoming a focus for local and national activities to educate families and health care professionals about effective methods to manage and control asthma.

updated annually since 2002, and publications based on the GINA reportsALTERhave been translated into many languages. In

In spite of these efforts, and the availability of effective therapies, international surveys provide ongoing evidence for suboptimal asthma control in many countries. It is clear that if recommendations contained within this report are to improve care of people with asthma, every effort must be made to encourage health care leaders to assure availability of, and access to, medications, and to develop means to implement and evaluate effective asthma management programs.

By 2012, there was increasing awareness of the heterogeneity of asthma, recognition of the spectrum of chronic airways disease, acknowledgement of major issues such as adherence and health literacy, and increasing interest in

	DO
individualized asthma care. In addition, a strong evidence baseNOThad emerged about effective methods for implementation
of clinical guidelines. These issues meant that provision of a framework for asthma care was not adequate in itself:
recommendations needed to be integrated into strategies that would be both clinically relevant and feasible for
-
implementation into busy clinical practice. To this end, the major revision of the GINA report published in May 2014,

presented recommendations in a user friendly way with extensive use of summary tables and flow-charts. For clinical

members of the GINA CommitteesMATERIALare solely responsible for the statements and conclusions presented in this publication. They receive no honoraria or expenses to attend the twice-yearly scientific review meetings, nor for the many hours spent

utility, recommendations for clinical practice were contained in the core GINA Report, while additional resources and

background supporting material were provided online at www.ginasthma.org. The same approach has been taken with the 2015 update of the GINA report.

It is a privilege for us to acknowledge the superlative work of all who have contributed to the success of the GINA

program, and the many people who participated in the present project. We particularly appreciate the outstanding and

dedicated work by Drs Suzanne Hurd (Scientific Director) and Claude Lenfant (Executive Director) over the many years since GINA was first established.

The work of GINA is now supported only by income generated from the sale of materials based on the report. The

reviewing the literature and contributing substantively to the writing of the report.

We hope you find this report to be a useful resource in the management of asthma and that, in using it, you will recognize the need to individualize the care of each and every asthma patient you see.

J Mark FitzGerald, MD	Helen K Reddel, MBBS PhD
Chair, GINA Board of Directors	Chair, GINA Science Committee

COPYRIGHTED	i

TABLE OF CONTENTS						REPRODUCE
TABLE OF CONTENTS
Methodology ......................................................................................................................................................................							vi
What’s new in GINA 2015?.................................................................................................................................................							ix
SECTION 1.ADULTS, ADOLESCENTS AND CHILDREN 6 YEARS AND OLDER...............................................................							1
Chapter 1. Definition, description, and diagnosis of asthma			.............................................................................................				1
Definition of asthma ....................................................................................................................................................					OR		2
Description of asthma..................................................................................................................................................							2
Making the initial diagnosis .........................................................................................................................................				ALTER			3
Differential diagnosis ...................................................................................................................................................							8
Making the diagnosis of asthma in special populations..............................................................................................							9
Chapter 2. Assessment of asthma ....................................................................................................................................							13
Overview....................................................................................................................................................................							14
Assessing asthma symptom control ..........................................................................................................................			NOT				15
Assessing future risk of adverse outcomes................................................................................................................							19
Role of lung function in assessing asthma control		....................................................................................................					19
Assessing asthma severity .........................................................................................................................................							21
Chapter 3. Treating asthma to control symptoms and minimize ..............................................................................risk							23
	-	DO
Part A. General principles of asthma management.......................................................................................................		DO					24
Treating other modifiable riskMATERIALfactors .......................................................................................................................							38
Long-term goals of asthma management..................................................................................................................							24
The patient-health care provider partnership...........................................................................................................							25
Control-based asthma management .........................................................................................................................							26
Part B. Medications and strategies for symptom control ...............................................................and risk reduction							28
Asthma medications ..................................................................................................................................................							29
Reviewing response and adjusting treatment...........................................................................................................							35
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Non-pharmacological interventions ..........................................................................................................................							39
Indications for referral for expert advice...................................................................................................................							41
Part . Guided asthma self-management education ........................................................................and skills training							42
Overview....................................................................................................................................................................							42
Skills training for effective use of inhaler devices .....................................................................................................							42
Adherence with medications and other advice.........................................................................................................							43

Asthma information							REPRODUCE	44
Asthma information								44
Training in guided asthma self-management............................................................................................................								45
Part D. Managing asthma with comorbidities and in special populations................................................................								47
Managing comorbidities............................................................................................................................................								47
Managing asthma in special populations or settings ................................................................................................								50
Chapter 4. Management of worsening asthma and exacerbations					.................................................................................			57
Overview....................................................................................................................................................................						OR		59
Diagnosis of exacerbations						OR		59
Diagnosis of exacerbations								59
Self-management of exacerbations with a written asthma action ...................................................................plan								60
Management of asthma exacerbations in primary care					ALTER			63
Management of asthma exacerbations in primary care								63
Management of asthma exacerbations in the emergency department ...................................................................								66
Chapter 5. Diagnosis of asthma, COPD and asthma-COPD overlap ....................................................syndrome (ACOS)								73
Objective....................................................................................................................................................................				NOT				74
Background to diagnosing asthma, COPD and ACOS				NOT				74
Background to diagnosing asthma, COPD and ACOS								74
Definitions..................................................................................................................................................................								75
Stepwise approach to diagnosis of patients with respiratory symptoms .................................................................								76
Future research			DO					82
Future research								82
SECTION 2.CHILDREN 5 YEARS AND YOUNGER............................................................................................................								83
		-						83
Chapter 6. Diagnosis and management of asthma in children 5 years ......................................................and younger								83
Part A. Diagnosis	MATERIAL							84
Part A. Diagnosis								84
Asthma and wheezing in young children...................................................................................................................								84
Clinical diagnosis of asthma.......................................................................................................................................								85
Tests to assist in diagnosis.........................................................................................................................................								87
Differential diagnosis.................................................................................................................................................								88
Part B. Assessment and management...........................................................................................................................								90
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Goals of asthma management...................................................................................................................................								90
Assessment of asthma...............................................................................................................................................								90
Medications for symptom control and risk reduction...............................................................................................								92
Reviewing response and adjusting treatment...........................................................................................................								96
Choice of inhaler device ............................................................................................................................................								96
Asthma self-management education for carers of young children...........................................................................								97
art . Management of worsening asthma and exacerbations in .................................children 5 years and younger								98

iii

Diagnosis of exacerbations								REPRODUCE	98
Diagnosis of exacerbations	........................................................................................................................................								98
Initial home management of asthma exacerbations.................................................................................................									99
Primary care or hospital management of acute asthma exacerbations..................................................................								101
Chapter 7. Primary prevention of asthma ......................................................................................................................								105
Factors contributing to the development of asthma ..............................................................................................								106
Prevention of asthma in children ............................................................................................................................								106
Advice about primary prevention of asthma...........................................................................................................							OR	108
SECTION 3.TRANSLATION INTO CLINICAL PRACTICE							OR	109
SECTION 3.TRANSLATION INTO CLINICAL PRACTICE			.................................................................................................					109
Chapter 8. Implementing asthma management strategies into health systems ...........................................................								109
Introduction						ALTER		110
Introduction								110
Adapting and implementing asthma clinical practice guidelines ............................................................................								110
Barriers and facilitators............................................................................................................................................								112
Evaluation of the implementation process..............................................................................................................					NOT			112
How can GINA help with implementation?					NOT			112
How can GINA help with implementation?								112
REFERENCES ....................................................................................................................................................................								113
	MATERIAL	-	DO
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				iv

TABLES AND FIGURES
Box 1-1.	Diagnostic flowchart for clinical practice – initial presentation.............................................................................						4
Box 1-2.	Diagnostic criteria for asthma in adults, adolescents, and children 6–11 years..................................................						5
Box 1-3.	Differential diagnosis of asthma in adults, adolescents and children 6–11 years ...............................................						8
Box 1-4.	Confirming the diagnosis of asthma in a patient already taking controller treatment........................................						10
Box 1-5.	How to step down controller treatment to help confirm the diagnosis of asthma ..............................................						11
Box 2-1.	Assessment of asthma in adults, adolescents, and children 6–11 years ..........................................................						15
Box 2-2.	GINA assessment of asthma control in adults, adolescents and children 6–11 years......................................						17
Box 2-3.	Specific questions for assessment of asthma in children 6–11 years ...............................................................						18
Box 2-4.	Investigating a patient with poor symptom control and/or exacerbations despite treatment.............................						22
Box 3-1.	Communication strategies for health care providers					REPRODUCE	25
Box 3-1.	Communication strategies for health care providers						25
Box 3-2.	The control-based asthma management cycle..................................................................................................						26
Box 3-3.	Population level versus patient level decisions about asthma treatment ..........................................................						27
Box 3-4.	Recommended options for initial controller treatment in adults and adolescents .............................................						30
Box 3-5.	Stepwise approach to control symptoms and minimize future risk				OR		31
Box 3-5.							31
Box 3-6.	Low, medium and high daily doses of inhaled corticosteroids...........................................................................						32
Box 3-7.	Options for stepping down treatment once asthma is well controlled ...............................................................						37
Box 3-8.	Treating modifiable risk factors to reduce exacerbations ..................................................................................						38
Box 3-9.	Non-pharmacological interventions - Summary.................................................................................................						39
Box 3-10.	Indications for considering referral for expert advice, where available..............................................................						41
Box 3-11.	Strategies to ensure effective use of inhaler devices ........................................................................................			ALTER			42
Box 3-12.	Poor medication adherence in asthma			ALTER			44
Box 3-12.	Poor medication adherence in asthma						44
Box 3-13.	Asthma information ............................................................................................................................................						45
Box 3-14.	Investigation and management of severe asthma.............................................................................................						55
Box 4-1.	Factors that increase the risk of asthma-related death .....................................................................................						59
Box 4-2.	Self-management of worsening asthma in adults and adolescents with a written asthma action plan.............						61
Box 4-3.			NOT				64
Box 4-3.	Management of asthma exacerbations in primary care (adults, adolescents, children 6–11 years) ................						64
Box 4-4.	Management of asthma exacerbations in acute care facility, e.g. emergency department ..............................						67
Box 4-5.	Discharge management after hospital or emergency department care for asthma ..........................................						72
Box 5-1.	Current definitions of asthma and COPD, and clinical description of ACOS.....................................................						75
Box 5-2a.		DO					77
Box 5-2a.	Usual features of asthma, COPD and ACOS ....................................................................................................						77
Box 5-2b.	-						77
Box 5-2b.	Features that if present favor asthma or COPD ................................................................................................						77
Box 5-3.	Spirometric measures in asthma, COPD and ACOS ........................................................................................						79
Box 5-4.	Summary of syndromic approach to diseases of chronic airflow limitation .......................................................						81
Box 5-5.	Specialized investigations sometimes used in distinguishing asthma and COPD ............................................						82
Box 6-1.	Probability of asthma diagnosis or response to asthma treatment in children 5 years and younger ................						85
Box 6-2.	Features suggesting a diagnosis of asthma in children 5 years and younger...................................................						86
Box 6-3.	Common differential diagnoses of asthma in children 5 years and younger.....................................................						89
Box 6-4.	GINA assessment of asthma control in children 5 years and younger..............................................................						91
Box 6-5.	Stepwise approach to long-term management of asthma in children 5 years and younger .............................						95
Box 6-6.	Low daily doses of inhaled corticosteroids for children 5 years and younger ...................................................						96
Box 6-7.	Choosing an inhaler device for children 5 years and younger...........................................................................						97
Box 6-8.	Primary care managementMATERIALof acute asthma or wheezing in children 5 years and younger............................						100
Box 6-9.	Initial assessment of acute asthma exacerbations in children 5 years and younger ......................................						101
Box 6-10.	Indications for immediate transfer to hospital for children 5 years and younger .............................................						102
Box 6-11.	Initial management of asthma exacerbations in children 5 years and younger...............................................						103
Box 7-1.	Advice about primary prevention of asthma in children 5 years and younger.................................................						108
Box 8-1.	Approach to implementation of the Global Strategy for Asthma Management and Prevention ......................						111
Box 8-2.	Essential elements required to implement a health-related strategy...............................................................						111
Box 8-3.	Examples of barriers to the implementation of evidence-based recommendations........................................						112
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Methodology

GINA SCIENCE COMMITTEE

The GINA Science Committee was established in 2002 to review published research on asthmaREPRODUCEmanagement and prevention, to evaluate the impact of this research on recommendations in GINA documents, and to provide yearly

updates to these documents. The members are recognized leaders in asthma research and clinical practice with the scientific expertise to contribute to the task of the Committee. They are invited to serve for a limited period and in a voluntary capacity. The Committee is broadly representative of adult and pediatric disciplines as well as from diverse geographic regions. The Science Committee meets twice yearly in conjunction with the American Thoracic Society (ATS) and European Respiratory Society (ERS) international conferences, to review asthma-related scientific literature. Statements of interest for Committee members are found on the GINA website www.ginasthma.org.

PROCESSES	ALTER	OR

For each meeting of the GINA Science Committee, a PubMed search is performed using search fields established by the Committee: 1) asthma, all fields, all ages, only items with abstracts, clinical trial, human; and 2) asthma and metaanalysis, all fields, all ages, only items with abstracts, human. Publications from July 1 to December 30 are reviewed during the following ATS meeting, and those from January 1 to June 30 during the following ERS meeting. The respiratory community is also invited to submit to the Chair of the GINA Science Committee any other peer-reviewed

Each abstract identified by the above search is allocated to at leastNOTtwo Committee members, but all members receive a copy of all of the abstracts and have the opportunity to provide comments. Members evaluate the abstract and, by his/her judgment, the full publication, and answer four written questions about whether the scientific data impact on

publications that they believe should be considered, providing an abstract and the full paper are submitted in (or

translated into) English; however, because of the comprehensive process for literature review, such ad hoc submissions have rarely resulted in substantial changes to the report.

GINA recommendations, and if so, what specific changes should be made. A list of all publications reviewed by the

Committee is posted on the GINA website.	DO

During Committee meetings, each publication that was- assessed by at least one member to potentially impact on the
MATERIAL

GINA report is discussed. Decisions to modify the report or its references are made by consensus by the full Committee,

or, if necessary, by an open vote of the full Committee. The Committee makes recommendations for therapies that have been approved for asthma by at least one regulatory agency, but decisions are based on the best available peer-

reviewed evidence and not on labeling directives from government regulators. In 2009, after carrying out two sample

reviews using the GRADE system,2 GINA decided not to adopt this methodology for its general processes because of

the major resource challenges that it would present. This decision also reflected that, unique among evidence based

recommendations in asthma, and most other therapeutic areas, GINA conducts an ongoing twice-yearly update of the evidence base for its recommendations. As with all previous GINA reports, levels of evidence are assigned to

GINA 2014

management recommendations where appropriate. A description of the current criteria is found in Table A. Updates of theCOPYRIGHTEDGlobal Strategy for Asthma Management and Prevention are generally issued in December of each year, based on evaluation of publications from July 1 of the previous year through June 30 of the year the update was completed.

GINA 2014 represented the first major revision of the strategy report since 2006. It was developed in the context of major changes in our understanding of airways disease, a focus on risk reduction as well as on symptom control, widespread interest in personalized asthma treatment, and extensive evidence about how to effectively translate and implement evidence into changes in clinical practice.3,4

vi Methodology

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2015 GINA Report 2015 May19

Preface REPRODUCE

TABLE OF CONTENTS