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148 Pages·2014·7.55 MB·English

by  Helen K. Reddel

The Global Initiative for Asthma is supported by unrestricted educational grants from:
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Boston Scientific
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Novartis E
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GLOBAL STRATEGY FOR
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ASTHRMA MANAGEMENT AND PREVENTION
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© 2014 Global Initiative for Asthma
Visit the GINA website at www.ginaasthma.org
© 2014 Global Initiative for Asthma
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Global Strategy for Asthma Management and Prevention
The GINA reports are available on www.ginasthma.org.
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Global Strategy for Asthma Management and Prevention 2014 (revisCion)
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GINA BOARD OF DIRECTORS* GINA SCIENCE COMMITTEE*
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J. Mark FitzGerald, MD, Chair Helen K. Reddel, MBBS PhD, Chair Ken Ohta, MD PhD (to May 2012)
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University of British Columbia Woolcock Institute of Medical Research National Hospital Organization Tokyo
Vancouver, BC, Canada Sydney, Australia National HEospital
Tokyo, Japan
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Eric D. Bateman, MD Neil Barnes, MD (to May 2013)
University of Cape Town Lung Institute London Chest Hospital Sore n Erik Pedersen, MD
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Cape Town, South Africa. London, UK Kolding Hospital
OKolding, Denmark
Louis-Philippe Boulet, MD Peter J Barnes, MD (to Dec 2012)
Université Laval National Heart and Lung Institute Emilio Pizzichini, MD
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Québec, QC, Canada London, UK Universidade Federal de Santa Catarina
E Florianópolis, SC, Brazil
Alvaro A. Cruz, MD Eric D. Bateman, MD
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Federal University of Bahia University of Cape Town Lung Institute Stanley J. Szefler, MD
Salvador, BA, Brazil Cape Town, South Africa. L Children's Hospital Colorado
A Aurora, CO, USA
Tari Haahtela, MD Allan Becker, MD
Helsinki University Central Hospital University of Manitoba T Sally E Wenzel, MD (to May 2012)
Helsinki, Finland Winnipeg, MB, CANADA O University of Pittsburgh
Pittsburgh, PA, USA
Mark L. Levy, MD Elisabeth Bel, MD (to MNay 2013)
The University of Edinburgh University of Amsterdam Brian Rowe, MD MSc (Consultant to

Edinburgh, UK Amsterdam, The NOetherlands Science Committee)
University of Alberta
Paul O'Byrne, MD Johan C. de JoDngste, MD PhD Edmonton, AL, Canada
McMaster University Erasmus Un iversity Medical Center
Hamilton, ON, Canada Rotterdam-, The Netherlands EXTERNAL REVIEWERS

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Pierluigi Paggiaro, MD Jeffrey M. Drazen, MD Mary Ip, MBBS MD
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University of Pisa Harvard Medical School University of Hong Kong Pokfulam
Pisa, Italy BoIston, MA, USA Hong Kong, ROC
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Soren Erik Pedersen, MD EJ. Mark FitzGerald, MD Alan Kaplan, MD
Kolding Hospital University of British Columbia Richmond Hill, ON, Canada
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Kolding, Denmark Vancouver, BC, Canada
A Huib Kerstjens, MD PhD
Manuel Soto-Quiroz, MD M Hiromasa Inoue, MD University of Groningen
Hospital Nacional de Niños Kagoshima University Groningen, The Netherlands
San José, Costa Rica Kagoshima, Japan
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Mike Thomas, MBBS PhD
Helen K. Reddel, MBBS PhD E Robert F. Lemanske, Jr., MD University of Southampton
Woolcock Institute of Medical Research University of Wisconsin Southampton, UK
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Sydney, Australia Madison, WI, USA
H Thys van der Molen, MD
Gary W. Wong, MD Paul O'Byrne, MD University of Groningen
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Chinese University of Hong Kong McMaster University Groningen, The Netherlands
Hong Kong, ROC I Hamilton, ON, Canada
R Monica Federico, MD
Children's Hospital Colorado
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Aurora, CO, USA
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* Disclosures for members of GINA Executive and Science Committees can be found at www.ginasthma.com
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GINA ASSEMBLY MEMBER OTHER CONTRIBUTORS
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CONTRIBUTORS
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Eva Mantzouranis, MD William Kelly, PharmD
Richard Beasley, MBChB DSc University Hospital University of New Mexico D
Medical Research Institute of New Heraklion, Crete, Greece Albuquerque, NM, USA
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Zealand
Wellington, New Zealand Patrick Manning, MD Christine Jenkins, MD
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St. James' Hospital The George Institute
Carlos Baena Cagnani, MD Dublin, Ireland Sydney, AustraliPa
Catholic University of Córdoba
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Cordoba, Argentina Yousser Mohammad, MD Stephen Lazarus, MD
Tishreen University School of Medicine University oRf California San Francisco
Yu-Zi Chen, MD Lattakia, Syria San Francisco, CA, USA

Children's Hospital of the Capital R
Beijing, China Hugo E. Neffen, MD Gregory Moullec PhD
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Clinica Alergia E Immunologie University of British Columbia
Maia Gotua, MD PhD Santa Fe, Argentina V ancouver, BC, Canada
Centre of Allergy & Immunology R
Republic of Georgia Ewa Nizankowska-Mogilnicka, MD Marielle Pijnenburg, MD PhD
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University School of Medicine Erasmus MC-Sophia Children's Hospital
Carlos Adrian Jiménez Krakow, Poland T Rotterdam, The Netherlands
San Luis Potosí, México L
Petr Pohunek, MD PhD A Mohsen Sadatsafavi, MD PhD
Guy Joos, MD University Hospital Motol University of British Columbia
Ghent University Hospital Czech Republic Vancouver, BC, Canada
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Ghent, Belgium
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Gustavo Rodrigo, MD D. Robin Taylor, MD DSc
Aziz Koleilat, MD Hospital Central de las Fuerzas Wishaw General Hospital
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Makassed Hospital Armadas, Montevideo, Uruguay Lanarkshire, UK
Beirut, Lebanon
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Joaquin Sastre, MD PhD Johanna van Gaalen, MD
Le Thi Tuyet Lan, MD PhD Universidad AutonDoma de Madrid Leiden University Medical Centre
University of Pharmacy and Medicine Madrid, Spain Leiden, The Netherlands
Ho Chi Minh City, Vietnam
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Wan-Cheng Tan, MD OTHER ASSISTANCE
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Jorg D. Leuppi, MD PhD iCAPTURE Centre for Cardiovascular
University Hospital and PulmAonary Research Kate Chisnall
Basel, Switzerland VancoIuver, BC, Canada Marianne Kirby
R Beejal Viyas-Price
T.K. Lim, MD GINA PROGRAM
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National University Hospital
Singapore TSuzanne Hurd, PhD
AScientific Director

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Preface
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Asthma is a serious global health problem affecting all age groups. Its prevalence is increasing in many countrieCs,
especially among children. Although some countries have seen a decline in hospitalizations and deaths from Uasthma,
asthma still imposes an unacceptable burden on health care systems, and on society through loss of productivity in the
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workplace and, especially for pediatric asthma, disruption to the family.
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In 1993, the National Heart, Lung, and Blood Institute collaborated with the World Health Organization to convene a
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workshop that led to a Workshop Report: Global Strategy for Asthma Management and Prevention.1 This was followed by
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the establishment of the Global Initiative for Asthma (GINA), a network of individuals, organizations, and public health
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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 initiateRd, as an ad hoc group of
dedicated asthma care experts from many countries. The Assembly works with the Scienc e Committee, the Board of
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Directors and the Dissemination and Implementation Committee to promote international collaboration and dissemination
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of information about asthma. The GINA report (“Global Strategy for Asthma Management and Prevention”), has been
updated annually since 2002, and publications based on the GINA reports have bee n translated into many languages. In
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2001, GINA initiated an annual World Asthma Day, raising awareness about the burden of asthma, and becoming a focus
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for local and national activities to educate families and health care professionals about effective methods to manage and
control asthma. T
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In spite of these efforts, and the availability of effective therapies, international surveys provide ongoing evidence for
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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 enTcourage health care leaders to assure availability of,
and access to, medications, and to develop means to implement aOnd evaluate effective asthma management programs.
By 2012, there was increasing awareness of the heterogeneity Nof asthma, recognition of the spectrum of chronic airways
disease, acknowledgement of major issues such as adheren ce and health literacy, and increasing interest in
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individualized asthma care. In addition, a strong evidence base had emerged about effective methods for implementation
of clinical guidelines. These issues meant that provision Dof a framework for asthma care was not adequate in itself:
recommendations needed to be integrated into strateg ies that would be both clinically relevant and feasible for
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implementation into busy clinical practice. To this en d, the recommendations in the 2014 GINA report are presented in a
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user friendly way with extensive use of summary tables and flow-charts. The report also includes two new chapters, one
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about management of asthma in children aged 0–5 years (previously published separately), and the other about the
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important topic of diagnosis of the asthma-CORPD overlap syndrome (ACOS); the latter chapter is co-published with the
Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD). For clinical utility, recommendations
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for clinical practice are contained in the core GINA Report, while appendices containing background supporting material
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are available online at www.ginasthma.org.
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It is a privilege for us to acknowledMge 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. This work has been supported by unrestricted

educational grants from variouDs companies (listed at the end of the report), together with income generated by GINA from
the sale of materials based on the report. The members of the GINA Committees are, however, solely responsible for the
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statements and conclusions presented in this publication. They receive no honoraria or expenses to attend the twice-
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yearly scientific review meetings, nor for the many hours spent reviewing the literature and contributing substantively to
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the writing of the report.
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We hope you find this updated report to be a useful resource in the management of asthma and that, in using it, you will
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recognize the neRed to individualize the care of each and every asthma patient you see.
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J Mark FitzGerald, MD Helen K Reddel, MBBS PhD
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Chair, GINA Board of Directors Chair, GINA Science Committee
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TABLE OF CONTENTS C
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Methodology ...................................................................................................................................................................... vi
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SECTION 1. ADULTS, ADOLESCENTS AND CHILDREN 6 YEARS AND OLDER ........................................O....................... 1
Chapter 1. Definition, description, and diagnosis of asthma .................................................................R............................ 1
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Definition of asthma .................................................................................................................................................... 2
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Description of asthma ..........................................................................................................R........................................ 2
Making the initial diagnosis ............................................................................................ ............................................. 3
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Differential diagnosis ................................................................................................O................................................... 8
Making the diagnosis of asthma in special populations ...................................... ........................................................ 9
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Chapter 2. Assessment of asthma ........................................................................E............................................................ 13
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Overview .................................................................................................................................................................... 14
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Assessing asthma symptom control ...................................................A....................................................................... 15

Assessing future risk of adverse outcomes...................................T............................................................................. 19
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Role of lung function in assessing asthma control .................................................................................................... 19
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Assessing asthma severity ......................................................................................................................................... 21

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Chapter 3. Treating asthma to control symptoms and minimize risk .............................................................................. 23
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Part A. General principles of asthma management ....................................................................................................... 24

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Long-term goals of asthma management .......... ........................................................................................................ 24
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The patient-health care provider partnership ........................................................................................................... 25
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Control-based asthma management ......R................................................................................................................... 26
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Part B. Medications and strategies for symptom control and risk reduction ............................................................... 28
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Asthma medications ...................A............................................................................................................................... 29
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Reviewing response and adjusting treatment ........................................................................................................... 35

Treating other modifiableD risk factors ....................................................................................................................... 38
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Non-pharmacological interventions .......................................................................................................................... 39
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Indications for referral for expert advice ................................................................................................................... 41
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Part C. Guided astGhma self-management education and skills training ........................................................................ 42
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Overview ...R................................................................................................................................................................. 42
Skills traiYning for effective use of inhaler devices ..................................................................................................... 42
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Adherence with medications and other advice ......................................................................................................... 43
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Asthma information ................................................................................................................................................... 44
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Training in guided asthma self-management ............................................................................................................ 45
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Part D. Managing asthma with comorbidities and in special populations ...............................................U................. 47
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Managing comorbidities ............................................................................................................................................ 47
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Managing asthma in special populations or settings ................................................................................................ 50
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Chapter 4. Management of worsening asthma and exacerbations ................................................................................. 57
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Overview .............................................................................................................................E....................................... 59
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Diagnosis of exacerbations ........................................................................................................................................ 59

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Self-management of exacerbations with a written asthma action plan ................................................................... 60
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Management of asthma exacerbations in primary care ........................................................................................... 63

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Management of asthma exacerbations in the emergency department ................................................................... 66
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Chapter 5. Diagnosis of asthma, COPD and asthma-COPD overlap syndrome (ACOS) .................................................... 73
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Objective ...........................................................................................L......................................................................... 74
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Background to diagnosing asthma, COPD and ACOS ................................................................................................ 74

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Definitions .................................................................................................................................................................. 75
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Stepwise approach to diagnosis of patients with respiraNtory symptoms ................................................................. 75
SECTION 2. CHILDREN 5 YEARS AND YOUNGER ............O. ............................................................................................... 83
Chapter 6. Diagnosis and management of asthma in cDhildren 5 years and younger ...................................................... 83
Part A. Diagnosis ................................................... ......................................................................................................... 84
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Asthma and wheezing in young children ....L............................................................................................................... 84
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Clinical diagnosis of asthma ....................................................................................................................................... 85
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Tests to assist in diagnosis ......................................................................................................................................... 87
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Differential diagnosis ................T................................................................................................................................. 88
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Part B. Assessment and management ........................................................................................................................... 90
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Goals of asthma management ................................................................................................................................... 90

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Assessment of asthma ............................................................................................................................................... 90
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Medications for symptom control and risk reduction ............................................................................................... 92
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Reviewing response and adjusting treatment ........................................................................................................... 96
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Choice of inhaler device ............................................................................................................................................ 96
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Asthma self-management education for carers of young children ........................................................................... 97
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Part C. Management of worsening asthma and exacerbations in children 5 years and younger ................................. 98
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DOiagnosis of exacerbations ........................................................................................................................................ 98
CInitial home management of asthma exacerbations ................................................................................................. 99
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Primary care or hospital management of acute asthma exacerbations.................................................................... 99
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Chapter 7. Primary prevention of asthma ............................................................................................................U.......... 105
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Factors contributing to the development of asthma .............................................................................................. 106
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Prevention of asthma in children ............................................................................................................................ 106
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Advice about primary prevention of asthma ........................................................................................................... 108
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SECTION 3. TRANSLATION INTO CLINICAL PRACTICE .................................................................E................................ 109
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Chapter 8. Implementing asthma management strategies into health systems ........................................................... 109

Introduction ...................................................................................................................R.......................................... 110
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Adapting and implementing asthma clinical practice guidelines ............................................................................ 110

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Barriers and facilitators............................................................................................................................................ 112
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Evaluation of the implementation process .............................................................................................................. 112
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How can GINA help with implementation? ...........................................L.................................................................. 112
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REFERENCES .................................................................................................................................................................... 113

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BOXED TABLES AND FIGURES
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Box 1-1. Diagnostic flowchart for clinical practice – initial presentation ............................................................................. 4
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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 ...................O............................ 8
Box 1-4. Confirming the diagnosis of asthma in a patient already taking controller treatment .........R............................... 10
Box 1-5. How to step down controller treatment to help confirm the diagnosis of asthma .............................................. 11
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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 yearsE ...................................... 17
Box 2-3. Specific questions for assessment of asthma in children 6–11 years ....................R........................................... 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 ........................................R................................................. 25
Box 3-2. The control-based asthma management cycle .................................................................................................. 26
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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 ado lescents ............................................. 30
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Box 3-5. Stepwise approach to control symptoms and minimize future risk .................................................................... 31
Box 3-6. Low, medium and high daily doses of inhaled corticosteroids..........E................................................................. 32
Box 3-7. Options for stepping down treatment once asthma is well controlled ............................................................... 37
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Box 3-8. Treating modifiable risk factors to reduce exacerbations .................................................................................. 38
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Box 3-9. Non-pharmacological interventions - Summary ................................................................................................. 39
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Box 3-10. Indications for considering referral for expert advice, where available .............................................................. 41
Box 3-11. Strategies to ensure effective use of inhaler devices ........ ................................................................................ 42
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Box 3-12. Poor medication adherence in asthma .............................................................................................................. 44
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Box 3-13. Asthma information ............................................................................................................................................ 45
Box 3-14. Investigation and management of severe asthma ...N.......................................................................................... 55
Box 4-1. Factors that increase the risk of asthma-related death ..................................................................................... 59

Box 4-2. Self-management of worsening asthma in adultOs and adolescents with a written asthma action plan ............. 61
Box 4-3. Management of asthma exacerbations in primary care ..................................................................................... 64
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Box 4-4. Management of asthma exacerbations in acute care facility, e.g. emergency department .............................. 67
Box 4-5. Discharge management after hospital or e mergency department care for asthma .......................................... 72
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Box 5-1. Current definitions of asthma and COP D, and clinical description of ACOS..................................................... 75
Box 5-2a. Usual features of asthma, COPD and LACOS .................................................................................................... 77
Box 5-2b. Features that favor asthma or COPDA ................................................................................................................ 77
Box 5-3. Spirometric measures in asthma,I COPD and ACOS ........................................................................................ 78
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Box 5-4. Summary of syndromic approach to diseases of chronic airflow limitation ....................................................... 80
Box 5-5. Specialized investigations somEetimes used in distinguishing asthma and COPD ............................................ 81
Box 6-1. Probability of asthma diagnosis or response to asthma treatment in children 5 years and younger ................ 85
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Box 6-2. Features suggesting a diagnosis of asthma in children 5 years and younger................................................... 86
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Box 6-3. Common differential diagnoses of asthma in children 5 years and younger ..................................................... 89
Box 6-4. GINA assessment of aMsthma 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 oDf inhaled corticosteroids for children 5 years and younger ................................................... 96
Box 6-7. Choosing an inhaler device for children 5 years and younger........................................................................... 97
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Box 6-8. Initial assessment of acute asthma exacerbations in children 5 years and younger ...................................... 100
Box 6-9. Indications foTr immediate transfer to hospital for children 5 years and younger ............................................. 100
Box 6-10. Initial manHagement of asthma exacerbations in children 5 years and younger ............................................... 102
Box 7-1. Advice about primary prevention of asthma in children 5 years and younger ................................................. 108
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Box 8-1. Approach to implementation of the Global Strategy for Asthma Management and Prevention ...................... 111
Box 8-2. EsseIntial elements required to implement a health-related strategy ............................................................... 111
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Box 8-3. Examples of barriers to the implementation of evidence-based recommendations ........................................ 112
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Methodology C
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GINA SCIENCE COMMITTEE
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The GINA Science Committee was established in 2002 to review published research on asthma manageOment and
prevention, to evaluate the impact of this research on recommendations in GINA documents, and to provide yearly
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updates to these documents. The members are recognized leaders in asthma research and clinical practice with the
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scientific expertise to contribute to the task of the Committee. They are invited to serve for a limited period and in a
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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 AmericRan Thoracic Society
(ATS) and European Respiratory Society (ERS) international conferences, to review asthm a-related scientific literature.
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Statements of interest for Committee members are found on the GINA website www.ginasthma.org.
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PROCESSES
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For each meeting of the GINA Science Committee, a PubMed search is performed using search fields established by
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the Committee: 1) asthma, all fields, all ages, only items with abstracts, clinical trial, human; and 2) asthma and meta-
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analysis, all fields, all ages, only items with abstracts, human. Publications from July 1 to December 30 are reviewed
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during the following ATS meeting, and those from January 1 to June 30 during the following ERS meeting. The
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respiratory community is also invited to submit to the Chair of the GINA Science Committee any other peer-reviewed

publications that they believe should be considered, providing an abstTract and the full paper are submitted in (or
translated into) English; however, because of the comprehensive prOocess for literature review, such ad hoc submissions
have rarely resulted in substantial changes to the report.
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Each abstract identified by the above search is allocated to at least two Committee members, but all members receive a
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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 writDten questions about whether the scientific data impact on
GINA recommendations, and if so, what specific chang es should be made. A list of all publications reviewed by the
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Committee is posted on the GINA website.
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During Committee meetings, each publication thaAt was assessed by at least one member to potentially impact on the
GINA report is discussed. Decisions to modify the report or its references are made by consensus by the full Committee,
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or, if necessary, by an open vote of the full CoRmmittee. The Committee makes recommendations for therapies that have
been approved for asthma by at least one rEegulatory agency, but decisions are based on the best available peer-
reviewed evidence and not on labeling diTrectives from government regulators. In 2009, after carrying out two sample
reviews using the GRADE system,2 GIANA 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
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recommendations in asthma, and most other therapeutic areas, GINA conducts an ongoing twice-yearly update of the

evidence base for its recommenDdations. As with all previous GINA reports, levels of evidence are assigned to
management recommendations where appropriate. A description of the current criteria is found in Table A. Updates of
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the Global Strategy for Asthma Management and Prevention are generally issued in December of each year, based on
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evaluation of publications from July 1 of the previous year through June 30 of the year the update was completed.
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GINA 2014 REVISION G
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The 2014 major rRevision commenced with an extensive review of key GINA figures relating to definition and diagnosis,
assessment and management of asthma, and management of acute asthma. A large number of asthma experts
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(primary care clinicians, specialists and other health professionals, and including members of all GINA Committees)
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were asked to provide feedback on these figures, with regard to 1) evidence, 2) clarity and 3) feasibility for
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implementation in clinical practice. Over 50 responses were received. The feedback underpinned the approach taken by
the ScCience Committee in revising key areas of the report, and strongly confirmed the decision to restructure the report
vi Methodology