Bronchial Asthma2025 GINA Guideline.pptx

GINA Bronchial Asthma

1. Presented By : Dr. Md. Mustofa Kamal Uddin Khan Assistant Professor (Medicine) GINA Current Update of Asthma

2. Topic: 1. Definition, description and diagnosis of asthma. 2. ⁠Assessment of asthma in adults. 3 . Principles of asthma management in adults

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4. What is GINA? The Global Initiative for Asthma. Established in 1993 by the National Heart, Lung, and blood institute and the World Health Organization. Aiming of increase awareness about asthma. GINA”s flagship publication, the Global Strategy for Asthma Management and Prevention (GINA report) first published 1995 has been updated annually since 2002.

5. Definition Asthma is a heterogeneous disease. Usually with chronic airway inflammation . Defined by history of symptoms: Wheeze, Shortness of Breath, Chest Tightness, and Cough. Symptoms vary over time and intensity with variable expiratory airflow. Airflow limitation may become persistent over time.

6. Asthma is a chronic inflammatory disorder of the airways associated with airway hyper-responsiveness that leads to recurrent episodes of Wheezing Breathlessness Coughing Chest tightness Particularly at night and in the early morning. These episodes are usually associated with widespread but variable airflow obstruction within the lung that is often reversible, either spontaneously or with treatment

7. Pathophysiology 8/26/2025 7 Asthma is an obstructive air way disease. fundamental problem is increased resistance to expiratory airflow as a result of reduction of caliber of airways Main pathology is the “Airway hyper-reactivity (AHR)” – the tendency for airways to narrow excessively in response to triggers that have little or no effect in normal individuals Airway obstruction occurs due to a combination of: • Inflammatory cell infiltration(in airway ) • Mucus hypersecretion with mucus plug formation • Smooth muscle contraction.

8. What’s new in GINA 2025 KEY CHANGES Biomarkers of Type 2 inflammation Role of Type 2 biomarkers (particularly blood eosinophils and fractional exhaled nitric oxide [ FeNO ]) in the diagnosis This information may be highly relevant when clinicians are assessing a patient’s eligibility for Type 2-targeted biologic therapy in clinical practice Risk factors for severe exacerbations in adults and adolescents ORACLE2 trial

9. Clinical Asthma Phenotypes Allergic Asthma : Begins in childhood, eosinophilic inflammation, good ICS response. Non-Allergic Asthma : No allergy, variable cell profiles, less responsive to ICS. Cough Variant Asthma : Cough is only symptom; responds to ICS.

10. Clinical Asthma Phenotypes Adult-Onset Asthma : Starts in adulthood, often non-allergic, may be corticosteroid-resistant. Asthma with Persistent Airflow Limitation : Possibly due to airway remodeling. Asthma with Obesity : Prominent symptoms, low eosinophilic inflammation.

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12. Genetic and environmental factor The development and course of asthma and the response to treatment are influenced by genetic determinants as well as environmental factor Atopy Atopy is the genetic propensity to produce IgE relationship between atopy and asthma is well established Common triggers Allergens ( IgE mediated) Outdoor allergens Pollens - from flowers, grass & trees Molds - of some fungi Indoor Allergens House dust mites Dander (or flakes)-- from skin, hair, feathers or excreta pets (dogs, cats) Molds - Insects – cockroach Food Allergens –(Rarely) Beef, prawn 8/26/2025 12

13. Common triggers (Continues) Irritants (non- IgE mediated) Tobacco smoke both active and passive Wood smoke smoke from gas and other cookers Strong odors perfumes and sprays, cosmetics cooking (especially with spices) Air-pollutants smoke and toxic gases from automobiles Upper respiratory tract infection viral infections, common cold Exercise - strenuous physical activities. Certain drugs β-blockers. (even eye drops), aspirin, NSAIDs Changes in season, weather and temperature asthma attack is likely if temperature lowers for 3°C or more than the previous day. exacerbations more in winter Stress Emotion - laughing, crying, sobbing, anxiety, depression Surgery Pregnancy Fear of an impending attack 8/26/2025 13

14. Diagnostic Tests for Asthma Spirometry with Bronchodilator responsiveness Use PEF if spirometry unavailable Look for variable expiratory airflow Document before starting ICS  

15. Bronchodilator responsiveness : ↑ FEV1 or FVC ≥12% and ≥200 mL Daily PEF variability: >10% in adults, >13% in children . Improvement after 4 weeks of ICS: ≥12% FEV1 or ≥20% PEF. Positive Bronchial Provocation test: ↓FEV1 ≥ 20% after Methacholine challenge ≥ 15% after Hypertonic saline ,Hyperventilation, Mannitol challenge

16. Role of Type 2 Biomarkers Support diagnosis when spirometry/PEF unavailable or inconclusive. FeNO : >50 ppb (adults), >35 ppb (children). Elevated blood eosinophils support Type 2 asthma. Lower levels do not rule out asthma.

17. FeNO Fractional exhaled nitric oxide concetration . Normal value: 5-25 ppb Values > 50 ppb are highly suggestive of eosinophilic airway inflammation. Use : diagnosis of asthma monitoring asthma to determine optimum inhaled corticosteroid dose

18. Other Test Allergy tests: Skin prick or Selective IgE Role of imaging : Not routine in asthma diagnosis Use to identify alternative or comorbid conditions CT may reveal bronchiectasis, emphysema

19. Differential diagnosis in asthma COPD (Chronic Obstructive Pulmonary Disease) Left ventricular failure (previously termed as cardiac asthma) Bronchiectasis Interstitial lung diseases Gastro esophageal reflux disease Post nasal drip syndrome Functional respiratory distress EGPA ( Churg –Strauss syndrome)

20. Principle of Asthma Management Requires a partnership between patient and healthcare provider Shared decision-making and Good communication by healthcare providers essential for good outcomes Focus on self-management education Low health literacy is linked with: Poor asthma control Increased exacerbations Worse inhaler technique

21. Goals of Asthma Management Long term asthma symptoms control: No/few symptoms No night waking Unimpaired physical activity Long term asthma risk minimization: No exacerbations Improved or stable lung function No requirement for maintenance systemic corticosteroids No medication side-effects

22. Treatment options for asthma(>12yrs) are shown in two tracks Track 1, with low dose ICS-formoterol as the reliever, is the preferred strategy Preferred because of the evidence that u sing ICS-formoterol as reliever reduces the risk of exacerbations compared with using a SABA reliever , with similar symptom control and lung function

23. Treatment options for asthma(>12yrs) are shown in two tracks Track 2, with SABA as the reliever , is an ‘alternative’ (non-preferred) strategy 1. Less effective than Track 1 for reducing severe exacerbations 2. Use Track 2 if Track 1 is not possible; 3. Consider Track 2 if a patient has good adherence with their controller, and has had no exacerbations in the last 12 months Before considering a regimen with SABA reliever , consider whether the patient is likely to continue to be adherent with daily controller – if not , they will be exposed to the risks of SABA only treatment .

24. In short cut step wise management in asthma Step 1: Occasional use of inhaled SABA Step 2 Introduction of regular preventer therapy : step 1 plus regular use of ICS Step 3: Add-on therapy inhaled SABA as required plus low dose ICS select any one : 1.inhaled LABAs / high dose ICS 800 μg /day / Oral leukotriene receptor antagonists Step 4: addition of a fourth drug (SABA+ICS +LABA ) and add one or more drug 1. ICS increased to 2000 µg . 2. Oral leukotriene receptor antagonists (e.g. montelukast ) 3. Sustained released Oral theophyllines 4. long-acting antimuscarinic agents, 5. slow-release β2-agonist Step 5:   Continuous or frequent use of oral glucocorticoids (prednisolone )therapy in addition to step 4: prednisolone therapy single daily dose in the morning at lowest amount necessary to control If not control on step 5 omalizumab – (a monoclonal antibody directed against IgE ) mepolizumab -- (humanized monoclonal antibody against IL5 it blocks the binding of IL-5 to its receptor on eosinophils) 8/26/2025 29

25. Management of asthma in low- and middle-income countries GINA supports the initiative by IUATLD towards a World Health Assembly Resolution on equitable access to affordable care for asthma, including inhaled medicines In the meantime, if Track 1 is not available due to lack of access or affordability , Track 2 treatment may be preferable, although less effective in reducing exacerbations.

26. Key changes to GINA severe asthma guide in 2025 Assessment of inflammatory phenotype If blood eosinophils or FeNO not elevated, repeat up to 3 times, at least 1–2 weeks after stopping OCS, or on lowest possible OCS dose

27. Key changes to GINA severe asthma guide in 2025 (continued) Anti-IL4R* (dupilumab): for severe eosinophilic/Type 2 asthma Not suggested if blood eosinophils (current or historic) >1500/µl Dupilumab now also approved for children ≥6 years with severe eosinophilic/Type 2 asthma, not on maintenance OCS ( Bacharier , NEJMed 2021) Anti-TSLP* ( tezepelumab ): now approved for severe asthma (age ≥12 years) Greater clinical benefit with higher blood eosinophils and/or higher FeNO Insufficient evidence in patients taking maintenance OCS

28. Key changes to GINA severe asthma guide in 2025 (continued)

29. Consider add-on biologic Type 2-targeted Treatments

30. Non-Pharmacological Strategies Pulmonary rehabilitation: Improves quality of life and exercise capacity Breathing exercises: supplement to therapy Healthy diet: recommend high fruit/vegetable intake Weight loss: effective with exercise or bariatric surgery Avoidance of Triggered Medication: Ask about asthma before prescribing NSAIDs or Beta-blockers Use beta-blockers cautiously in acute cardiac events.

31. Non-Pharmacological Strategies Avoidance of occupational or domestic exposures: Ask about occupational exposure in all adult onset asthma patient Identify and eliminate sensitizer Avoidance Indoor Allergen: General allergen avoidance not routinely recommended Damp/mold remediation may help adults Consider avoidance only if sensitized + evidence of benefit

32. Non-Pharmacological Strategies Avoidance of indoor air pollution: Encourage people to use non polluting heating and cooking Avoid outdoor air pollution/weather extremes Limit exposure to food allergens (if confirmed) Address emotional stress: Breathing/relaxation techniques Provide comprehensive social support where available

33. VACCINATIONS Influenza Respiratory syncytial virus Other vaccines: Pneumococcal, Pertussis , COVID-19

34. OTHER THERAPIES Bronchial thermoplasty Vitamin D

35. Assessing Asthma Severity Definition of Severe Asthma : Uncontrolled despite optimized treatment with high-dose ICS-LABA. Requires high-dose ICS-LABA to maintain control. Must be distinguished from difficult-to-treat asthma due to modifiable factors.

36. Severe Asthma Need to excluded: Incorrect inhaler technique (up to 80% prevalence). Poor adherence to medications. Incorrect diagnosis (Heart failure, Inducible laryngeal obstruction) Multimorbidities ( Rhinosinusitis , Obesity, GERD, OSA). Ongoing exposure to irritants ( e.g : tobacco smoke).

37. The most common problems that need to be excluded before making a diagnosis of severe asthma are: Poor inhaler technique ( Upto 80% of community patients). Poor medication adherence Incorrect diagnosis of asthma, with symptoms due to alternative conditions such as inducible laryngeal obstruction, cardiac failure or lack of fitness. Multimorbidity such as rhinosinusitis, GERD, obesity and obstructive sleep apnoea . Ongoing exposure to sensitizing or irritant agents in the home or work environment.

38. Moderate and Mild Asthma Moderate: Controlled with Step 3 or 4 treatment (low/medium-dose ICS-LABA). Mild: Controlled with low-intensity treatment (e.g., as-needed low-dose ICS- formoterol

39. 46 Occupational asthma

40. Occupational asthma Occupational asthma may be defined as asthma induced at work by exposure to occupation-related agents, which are mainly inhaled at the workplace The most characteristic feature in the medical history is symptoms of asthma that worsens on workdays and improves on rest days or holidays. This is asthma due to specific workplace sensitizers and may account for 10% of adult-onset asthma Mainly occur in this group Chemical workers Farmers Textile workers Poultry breeders Press & printing workers 8/26/2025 47

41. 8/26/2025 48 Asthma in pregnancy

42. Asthma in pregnancy Asthma during pregnancy follows the rule of one-third— one-third asthmatics become worse, one-third remains same and One-third improves. Women with well-controlled asthma usually have good pregnancy outcomes. Pregnancy in women with more severe asthma can precipitate worsening control and lead to increased maternal and neonatal morbidity In pregnant asthmatics there is increased risk of:   Uncontrolled asthma: associated with Maternal complication hyperemesis, hypertension, pre-eclampsia, vaginal haemorrhage , complicated labour Fetal complication intrauterine growth restriction and low birth weight, preterm birth, increased perinatal mortality, neonatal hypoxia 8/26/2025 49

43. Asthma with hypertension Virtually all antihypertensive in low dose can be used in asthma except propanolol Drug of choice is calcium channel blockers with thiazide diuretics -singly or in combination Angiotensin receptor blockers (e.g. losartan, valsartan) are preferred to ACE Inhibitors (because the latter may induce dry cough). Non selective β-blockers must be avoided, But selective βblockers can be used Asthma with Ischaemic Heart Diseases (Stable & Unstable Angina) Aspirin should be tried first ,If not tolerated clopidogrel should be used Anti- anginal nitrates & calcium channel bIocker (diltiazem & verapamil) are the drug of choice Cardioselective β-blockers (e.g. metaprolol) may be used. Asthma control should be optimum to avoid hypoxemia. Asthma with heart failure   Diuretic is the drug of choice ACE Inhibitors should be continued if tolerated Carvedilol maybe used in lower doses Digoxin can be used Asthma with Arrhythmia Calcium channel blockers (diltiazem / verapamil) is used in supraventricular arrhythmias (e.g. atrial fibrillation) Digoxin is the drug of choice to control ventricular rate Amiodarone can be used. Try to avoid aminophylline / theophylline to treat asthma. 8/26/2025 50

44. Difference between cardiac asthma and bronchial asthma clinically?   bronchial asthma cardiac asthma age young age older history family HO ++ HO atopy ++ HO I timing of dyspnea occur at late part of night early part of night orthopnea Absent present (PND—in case OF LVF) cough and sputum scanty mucoid sputum and tenacious profuse and frothy expectoration wheeze and more marked (++++) less marked () pulse pulsus paradoxus pulsus alternans BP normal hypertension JVP normal may be raised apex beat normal heaving – in hyptertension auscultation Rhonchi more marked (+++++) creps is absent less marked (+++) creps present ,gallop rhythm 8/26/2025 51

45.   Asthma COPD A ge young old usually, after 40 F amily history , atopy Present Absent HO of triggering factor tree and grass pollen, cat and dog dander, Cold air exposure, drugs NAID , viral RTI may provoke the symptoms Usually not, but. respiratory tract infection aggravate fee symptoms C ough usually non-productive or mucoid sputum, productive H ave diurnal variation more marked in the morning not so G eneral examination tachycardia, and tachypnea in sever case usually feature of Type II Resp. failure Eye- congested • Tongue -cyanosed • Palm— warm • Pulse -bounding pulse • Flapping tremor may present 8/26/2025 52

46. ASTHMA COPD Respiratory exam Wheeze lip pursing, prominence of accessory muscle of neck , engorge neck vein apex beat palpable in emphysema not palpable upper border of liver dullness is normal is lower in emphysema Crepitation absent may present feature of pulmonale HTN and corpulmonale not so palpable-JP2 left para sternal heave epigastric pulsation loudP2 tender hepatomegaly raised JVP depended edema 8/26/2025 53

47. Attention