Preparing the Assignment
Follow these guidelinesLinks to an external site. when completing each component of the assignment. Contact your course faculty if you have questions.
General Instructions
Explore current literature and clinical practice guidelines to complete the clinical treatment protocol template.
- Complete the protocol outline templateLinks to an external site. to develop a protocol for asthma treatment. Use of the template is required. A 10% deduction will be applied if the template is not used. See the rubric.
- Provide references for your protocol at the bottom of the form where indicated. References should come from the following sources:
- Asthma Clinical Practice Guideline
- Course Textbook (for individual medication information)
- Journal Articles from within the last five years as defined by program expectationsLinks to an external site..
- Follow APA grammar, spelling, word usage, and punctuation rules consistent with formal, scholarly writing.
- No more than one short direct quote (15 words or less) may be used in this assignment.
- First person should not be used within this assignment.
- At least three scholarly references must be used for this assignment.
- Abide by Chamberlain University's academic integrity policy.
Include the following sections (detailed criteria listed below and in the grading rubric).
Pharmacological Treatment
- Correctly complete all blanks for the preferred and alternative medication for each step of therapy noted in the CPG.
- List medications in order according to the CPG.
- List generic medication names for each category.
- Provide an in-text citation under the completed table.
Treatment Differences in Adults and Children
- Correctly list the first line of initial pharmacologic treatment in step one; track one for asthmatic adults. (7a on the form)
- Correctly list the first line of initial pharmacologic treatment in step one, track one for asthmatic children ages 6-11. (7b on the form)
- Correctly list drug dose, route, frequency, instructions, precautions, drug cost, and education for adult and pediatric clients.
- Provide in-text citations under the information for adults and pediatric clients.
Treatment Monitoring
- List the physical assessments required for monitoring the first-line medications prescribed to adults for track one, step one.
- List the pulmonary function tests required for monitoring the first-line medications prescribed to adults for track one, step one.
- List the laboratory tests required for monitoring the first-line medications prescribed to adults for track one, step one.
- Provide an in-text citation under the treatment monitoring section.
Treatment Failure
- Describe how you will know that treatment is not working or needs to progress.
- Describe the next step if treatment is not working or needs to progress.
- Describe the indicators that would demonstrate that the client requires a higher level of care.
- Provide an in-text citation under the treatment failure section.
GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION
Updated 2022
© 2022 Global Initiative for Asthma
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Global Strategy for Asthma Management and Prevention (2022 update)
The reader acknowledges that this report is intended as an evidence-based asthma management strategy, for the use of health professionals and policy-makers. It is based, to the best of our knowledge, on current best evidence and medical knowledge and practice at the date of publication. When assessing and treating patients, health professionals are strongly advised to use their own professional judgment, and to take into account local and national regulations and guidelines. GINA cannot be held liable or responsible for inappropriate healthcare associated with the use of this document, including any use which is not in accordance with applicable local or national regulations or guidelines.
This document should be cited as: Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2022. Available from: www.ginasthma.org
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Table of contents Tables and figures …………………………………………………………………………………………………………………………………………. 5
Preface ………………………………………………………………………………………………………………………………………………………….. 7
Members of GINA committees (2019-20) …………………………………………………………………………………………………………. 8
Methodology ………………………………………………………………………………………………………………………………………………… 10
What’s new in GINA 2022? ……………………………………………………………………………………………………………………………. 14
Advice on asthma management during the COVID-19 pandemic……………………………………………………………………. 17
SECTION 1. ADULTS, ADOLESCENTS AND CHILDREN 6 YEARS AND OLDER ………………………………………………….. 19
Chapter 1. Definition, description, and diagnosis of asthma ………………………………………………………………………… 19
Definition of asthma ………………………………………………………………………………………………………………………………… 20
Description of asthma ……………………………………………………………………………………………………………………………… 20
Making the initial diagnosis ………………………………………………………………………………………………………………………. 21
Confirming the diagnosis of asthma in patients already taking controller treatment …………………………………………. 26
Differential diagnosis ……………………………………………………………………………………………………………………………….. 27
How to make the diagnosis of asthma in other contexts ………………………………………………………………………………. 28
Chapter 2. Assessment of asthma ……………………………………………………………………………………………………………….. 31
Overview ……………………………………………………………………………………………………………………………………………….. 32
Assessing asthma symptom control ………………………………………………………………………………………………………….. 34
Assessing future risk of adverse outcomes ………………………………………………………………………………………………… 38
Role of lung function in assessing asthma control ……………………………………………………………………………………….. 39
Assessing asthma severity ………………………………………………………………………………………………………………………. 40
Chapter 3. Treating asthma to control symptoms and minimize risk …………………………………………………………….. 45
Part A. General principles of asthma management …………………………………………………………………………………………. 46
Long-term goals of asthma management …………………………………………………………………………………………………… 47
The patient-health care provider partnership ………………………………………………………………………………………………. 47
Personalized control-based asthma management ………………………………………………………………………………………. 48
Part B. Medications and strategies for symptom control and risk reduction ………………………………………………………… 51
Asthma medications ………………………………………………………………………………………………………………………………… 52
Asthma treatment tracks for adults and adolescents ……………………………………………………………………………………. 54
Step 1 ……………………………………………………………………………………………………………………………………………………. 64
Step 2 ……………………………………………………………………………………………………………………………………………………. 66
Step 3 ……………………………………………………………………………………………………………………………………………………. 69
Step 4 ……………………………………………………………………………………………………………………………………………………. 70
Step 5 ……………………………………………………………………………………………………………………………………………………. 72
Reviewing response and adjusting treatment ……………………………………………………………………………………………… 73
Treating other modifiable risk factors …………………………………………………………………………………………………………. 76
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Other therapies ………………………………………………………………………………………………………………………………………. 77
Non-pharmacological strategies ……………………………………………………………………………………………………………….. 79
Indications for referral for expert advice …………………………………………………………………………………………………….. 87
Part C. Guided asthma self-management education and skills training ……………………………………………………………… 88
Skills training for effective use of inhaler devices ………………………………………………………………………………………… 88
Adherence with medications and other advice ……………………………………………………………………………………………. 89
Asthma information …………………………………………………………………………………………………………………………………. 91
Training in guided asthma self-management ……………………………………………………………………………………………… 92
Part D. Managing asthma with multimorbidity and in specific populations ………………………………………………………….. 94
Managing comorbidities …………………………………………………………………………………………………………………………… 94
Managing asthma in specific populations or settings …………………………………………………………………………………… 97
Part E. Difficult-to-treat and severe asthma in adults and adolescents …………………………………………………………….. 104
Definitions: uncontrolled, difficult-to-treat and severe asthma ……………………………………………………………………… 105
Prevalence: how many people have severe asthma? ………………………………………………………………………………… 105
Importance: the impact of severe asthma…………………………………………………………………………………………………. 106
Investigate and manage difficult-to-treat asthma in ADULTS AND ADOLESCENTS ……………………………………… 111
Assess and treat severe asthma phenotypes ……………………………………………………………………………………………. 113
Manage and monitor severe asthma treatment …………………………………………………………………………………………. 120
Chapter 4. Management of worsening asthma and exacerbations ………………………………………………………………. 123
Overview ……………………………………………………………………………………………………………………………………………… 125
Diagnosis of exacerbations …………………………………………………………………………………………………………………….. 126
Self-management of exacerbations with a written asthma action plan …………………………………………………………. 126
Management of asthma exacerbations in primary care (adults, adolescents, chldren 6–11 years) ………………….. 130
Management of asthma exacerbations in the emergency department (adults, adolescents, children 6–11 years) 133
Chapter 5. Diagnosis and initial treatment of adults with features of asthma, COPD or both (‘asthma-COPD overlap’) …………………………………………………………………………………………………………………………………………………….. 141
Objectives ……………………………………………………………………………………………………………………………………………. 143
Background to diagnosing asthma and/or COPD in adult patients ………………………………………………………………. 143
Assessment and management of patients with chronic respiratory symptoms ………………………………………………. 144
Future research …………………………………………………………………………………………………………………………………….. 149
SECTION 2. CHILDREN 5 YEARS AND YOUNGER …………………………………………………………………………………………… 151
Chapter 6. Diagnosis and management of asthma in children 5 years and younger ……………………………………. 151
Part A. Diagnosis ……………………………………………………………………………………………………………………………………… 152
Asthma and wheezing in young children …………………………………………………………………………………………………. 152
Clinical diagnosis of asthma …………………………………………………………………………………………………………………… 153
Tests to assist in diagnosis …………………………………………………………………………………………………………………….. 156
Differential diagnosis …………………………………………………………………………………………………………………………….. 157
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Part B. Assessment and management ………………………………………………………………………………………………………… 159
Goals of asthma management ………………………………………………………………………………………………………………… 159
Assessment of asthma ………………………………………………………………………………………………………………………….. 159
Medications for symptom control and risk reduction …………………………………………………………………………………… 161
Asthma treatment steps for children aged 5 years and younger ………………………………………………………………….. 163
Reviewing response and adjusting treatment …………………………………………………………………………………………… 166
Choice of inhaler device ………………………………………………………………………………………………………………………… 166
Asthma self-management education for carers of young children ………………………………………………………………. 167
Part C. Management of worsening asthma and exacerbations in children 5 years and younger …………………………. 168
Diagnosis of exacerbations …………………………………………………………………………………………………………………….. 168
Initial home management of asthma exacerbations …………………………………………………………………………………… 169
Primary care or hospital management of acute asthma exacerbations in children 5 years or younger ……………… 171
Chapter 7. Primary prevention of asthma …………………………………………………………………………………………………… 175
Factors contributing to the development of asthma in children ……………………………………………………………………. 176
Factors associated with increased or decreased risk of asthma in children …………………………………………………… 176
Advice about primary prevention of asthma ……………………………………………………………………………………………… 179
SECTION 3. TRANSLATION INTO CLINICAL PRACTICE …………………………………………………………………………………… 181
Chapter 8. Implementing asthma management strategies into health systems ……………………………………………. 181
Introduction ………………………………………………………………………………………………………………………………………….. 182
Adapting and implementing asthma clinical practice guidelines …………………………………………………………………… 182
Barriers and facilitators ………………………………………………………………………………………………………………………….. 184
Examples of high impact implementation interventions ………………………………………………………………………………. 184
Evaluation of the implementation process ………………………………………………………………………………………………… 184
How can GINA help with implementation? ……………………………………………………………………………………………….. 185
REFERENCES ……………………………………………………………………………………………………………………………………………….. 186
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Tables and figures DIAGNOSIS Box 1-1. Diagnostic flowchart for clinical practice 22 Box 1-2. Diagnostic criteria for asthma in adults, adolescents, and children 6–11 years 23 Box 1-3. Steps for confirming the diagnosis of asthma in a patient already taking controller treatment 26 Box 1-4. How to step down controller treatment to help confirm the diagnosis of asthma 27 Box 1-5. Differential diagnosis of asthma in adults, adolescents and children 6–11 years 27
ASSESSMENT Box 2-1. Assessment of asthma in adults, adolescents, and children 6–11 years 33 Box 2-2. GINA assessment of asthma control in adults, adolescents and children 6–11 years 36 Box 2-3. Specific questions for assessment of asthma in children 6–11 years 37 Box 2-4. Investigating a patient with poor symptom control and/or exacerbations despite treatment 43
ASTHMA MANAGEMENT Box 3-1. Communication strategies for health care providers 47 Box 3-2. The asthma management cycle for personalized asthma care 48 Box 3-3. Population level versus patient level decisions about asthma treatment 50
Initial treatment choices Box 3-4A. Initial asthma treatment – recommended options for adults and adolescents 55 Box 3-4Bi. Selecting initial controller treatment in adults and adolescents with a diagnosis of asthma (V1) 56 Box 3-4Bii. Selecting initial controller treatment in adults and adolescents with a diagnosis of asthma (V2) 57 Box 3-4C. Initial asthma treatment – recommended options for children aged 6–11 years 58 Box 3-4Di. Selecting initial controller treatment in children aged 6–11 years with a diagnosis of asthma (V1) 59 Box 3-4Dii. Selecting initial controller treatment in children aged 6–11 years with a diagnosis of asthma (V2) 60
Main treatment figures Box 3-5A. Personalized management for adults and adolescents to control symptoms and minimize future risk 61 Box 3-5B. Personalized management for children 6–11 years to control symptoms and minimize future risk 62 Box 3-6. Low, medium and high daily metered doses of inhaled corticosteroids (alone or with LABA) 63
Ongoing management Box 3-7. Options for stepping down treatment once asthma is well controlled 75 Box 3-8. Treating potentially modifiable risk factors to reduce exacerbations 76 Box 3-9. Non-pharmacological interventions – summary 79 Box 3-10. Effectiveness of avoidance measures for indoor allergens 83 Box 3-11. Indications for considering referral for expert advice, where available 87 Box 3-12. Strategies to ensure effective use of inhaler devices 89 Box 3-13. Poor medication adherence in asthma 90 Box 3-14. Asthma information 91
Difficult-to-treat and severe asthma Box 3-15. What proportion of adults have difficult-to-treat or severe asthma? 105 Box 3-16A. Decision tree – investigate and manage difficult to treat asthma in adult and adolescent patients 107 Box 3-16B. Decision tree – assess and treat severe asthma phenotypes 108 Box 3-16C. Decision tree – consider add-on biologic Type 2-targeted treatments 109 Box 3-16D. Decision tree – monitor and manage severe asthma treatment 110
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EXACERBATIONS Box 4-1. Factors that increase the risk of asthma-related death 125 Box 4-2. Self-management of worsening asthma in adults and adolescents with a written asthma action plan 129 Box 4-3. Management of asthma exacerbations in primary care (adults, adolescents, children 6–11 years) 131 Box 4-4. Management of asthma exacerbations in acute care facility, e.g. emergency department 135 Box 4-5. Discharge management after hospital or emergency department care for asthma 139
ASTHMA, COPD AND ASTHMA+COPD Box 5-1. Current definitions of asthma and COPD, and clinical description of asthma-COPD overlap 144 Box 5-2. Approach to initial treatment in patients with asthma and/or COPD 145 Box 5-3. Spirometric measures in asthma and COPD 146 Box 5-4. Specialized investigations sometimes used in distinguishing asthma and COPD 148 Box 6-1. Probability of asthma diagnosis in children 5 years and younger 153
CHILDREN 5 YEARS AND YOUNGER Box 6-2. Features suggesting a diagnosis of asthma in children 5 years and younger 154 Box 6-2A. Questions that can be used to elicit features suggestive of asthma 155 Box 6-3. Common differential diagnoses of asthma in children 5 years and younger 157 Box 6-4. GINA assessment of asthma control in children 5 years and younger 160 Box 6-5. Personalized management of asthma in children 5 years and younger 165 Box 6-6. Low daily doses of inhaled corticosteroids for children 5 years and younger 166 Box 6-7. Choosing an inhaler device for children 5 years and younger 167 Box 6-8. Management of acute asthma or wheezing in children 5 years and younger 170 Box 6-9. Initial assessment of acute asthma exacerbations in children 5 years and younger 171 Box 6-10. Indications for immediate transfer to hospital for children 5 years and younger 172 Box 6-11. Initial emergency department management of asthma exacerbations in children 5 years and younger 173
PRIMARY PREVENTION OF ASTHMA IN CHILDREN Box 7-1. Advice about primary prevention of asthma in children 5 years and younger 179
IMPLEMENTATION STRATEGIES Box 8-1. Approach to implementation of the Global Strategy for Asthma Management and Prevention 183 Box 8-2. Essential elements required to implement a health-related strategy 183 Box 8-3. Examples of barriers to the implementation of evidence-based recommendations 184 Box 8-4. Examples of high-impact interventions in asthma management 184
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Preface Asthma is a serious global health problem affecting all age groups. Its prevalence is increasing in many countries, 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.
The Global Initiative for Asthma was established in 1993 by the National Heart, Lung, and Blood Institute and the World Health Organization, with the aim of increasing awareness about asthma and providing a mechanism to translate scientific evidence into improved asthma care worldwide. In 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. GINA”s flagship publication, the Global Strategy for Asthma Management and Prevention (‘GINA report’), first published in 1995,1 has been updated annually since 2002, with pivotal changes in 2006, 2014 and 2019. The main GINA report contains recommendations for clinical practice and brief supporting evidence, while additional resources and supporting material are provided online at www.ginasthma.org. Publications and resources based on the GINA reports have been translated into many languages. GINA is independent of industry. Its work is supported only by income generated from the sale and licensing of its resources.
We acknowledge the superlative work of all who have contributed to the success of the GINA program, and the many people who have participated in it. In particular, we recognize the outstanding and dedicated work of Drs Suzanne Hurd as Scientific Director and Claude Lenfant as Executive Director over the many years since GINA was first established, until their retirement in 2015. Through their tireless contributions, Dr Hurd and Dr Lenfant fostered and facilitated the development of GINA. In 2016, we were delighted to welcome Ms Rebecca Decker, BS, MSJ, as the Program Director (now Executive Director) for GINA, and we appreciate the commitment and skills that she has brought to this demanding role. The members of the GINA Committees are solely responsible for the statements and conclusions presented in this publication. They receive no honoraria or reimbursement of expenses for their many hours of work in reviewing evidence or attending meetings. The GINA Advocates and Assembly, dedicated asthma care experts from many countries, work with the Science Committee, the Board of Directors and the Dissemination and Implementation Committee to promote international collaboration and dissemination of information about asthma.
We share the sadness that the global asthma community feels at the loss of Mark FitzGerald (18 June 1955–18 January 2022). In his 25 years of work with GINA, Mark was a compassionate leader and strong advocate for improving asthma diagnosis and management. Mark’s guidance will be missed dearly but his research, legacy, and commitment to helping the world breathe better remain a guiding force. In Mark’s honor, GINA is establishing a scholarship for junior researchers from low- or middle-income countries.
In spite of all of the above efforts, and the availability of effective therapies, international data provide ongoing evidence for suboptimal asthma control in many countries. The majority of the burden of asthma morbidity and mortality occurs in low- and middle-income countries, and is avoidable. 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, effective quality-assured medications, and to develop means to implement and evaluate effective asthma management programs.
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.
Helen K Reddel, MBBS PhD Louis-Philippe Boulet, MD Chair, GINA Science Committee Chair, GINA Board of Directors
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Members of GINA committees (2019-20)
GINA SCIENTIFIC COMMITTEE
Helen K. Reddel, MBBS PhD, Chair Woolcock Institute of Medical Research, University of Sydney Sydney, Australia
Leonard B. Bacharier, MD Vanderbilt University Medical Center Nashville, TN, USA
Eric D. Bateman, MD University of Cape Town Lung Institute Cape Town, South Africa
Louis-Philippe Boulet, MD Université Laval Québec, QC, Canada
Christopher Brightling, FMedSci, PhD Leicester NIHR Biomedical Research Centre, University of Leicester Leicester, UK
Guy Brusselle, MD, PhD Ghent University Hospital Ghent, Belgium
Roland Buhl, MD PhD Mainz University Hospital Mainz, Germany
Jeffrey M. Drazen Brigham and Woman’s Hospital Boston, MA, USA
Liesbeth Duijts, MD MSc Phd University Medical Center Rotterdam, The Netherlands
J. Mark FitzGerald, MD† University of British Columbia Vancouver, BC, Canada