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This Guidelines summary is taken from the GINA 2020 pocket guide for asthma management and prevention. It outlines recommendations for assessing patients with asthma. 

Download the full global strategy for asthma management and prevention:

Global strategy for asthma management and prevention

2020 pocket guide for asthma management and prevention

This summary is adapted from the Pocket Guide, which itself is a brief summary of the GINA 2020 report for primary healthcare providers. It does not contain all of the information required for managing asthma, for example, about the safety of treatments, and it should be used in conjunction with the full GINA 2020 report. When assessing and treating patients, health professionals are strongly advised to use their own professional judgement and to take into account local and national regulations and guidelines.

Refer to the Guidelines in Practice article, ’Key learning points: uncontrolled and severe asthma’, by GINA Executive Board member Dr Mark L Levy, to learn more about why deaths from asthma in the UK remain high compared with other high-income countries; key points for the effective management of most patients with asthma; and how to recognise when a patient with asthma should be referred to a specialist.

Jump to:

Assessing patients with asthma

How to assess asthma control

How to investigate uncontrolled asthma

 

View the full group of Guidelines GINA asthma strategy summaries at guidelines.co.uk/ginaasthma.

 

Assessing patients with asthma

Take every opportunity to assess patients with asthma, particularly when they are symptomatic or after a recent exacerbation, but also when they ask for a prescription refill. In addition, schedule a routine review at least once a year.

Table 1: How to assess a patient with asthma

1. Asthma control—assess both symptoms and risk factors

  • Assess symptom control over the last four weeks (see Table 2)

  • Identify any modifiable risk factors for poor outcomes (see Table 2)

  • Measure lung function before starting treatment, three to six months later, and then periodically, e.g. at least yearly in most patients

2. Are there any comorbidities?

  • These include rhinitis, chronic rhinosinusitis, gastro-oesophageal reflux disease (GORD), obesity, obstructive sleep apnoea, depression and anxiety

  • Comorbidities should be identified as they may contribute to respiratory symptoms, flare-ups and poor quality of life. Their treatment may complicate asthma management

3. Treatment issues

  • Record the patient’s treatment. Ask about side-effects

  • Watch the patient using their inhaler, to check their technique

  • Have an open empathic discussion about adherence

  • Check that the patient has a written asthma action plan

  • Ask the patient about their goals and preferences for asthma treatment

 

For more information on treatment issues, refer to the pocket guide.

Table 2: Assessment of symptom control and future risk

A. Assessment of symptom control Level of asthma symptom control

In the past four weeks, has the patient had:

Well controlled

Partly controlled

Uncontrolled

Daytime symptoms more than twice/week?

Yes

No

(delete as appropriate)

None of these

1–2 of these

3–4 of these

Any night waking due to asthma?

Yes

No

(delete as appropriate)

SABA reliever needed more than twice/week?

Yes

No

(delete as appropriate)

Any activity limitation due to asthma?

Yes

No

(delete as appropriate)

B. Risk factors for poor asthma outcomes

Assess risk factors at diagnosis and periodically at least every 1–2 years, particularly for patients experiencing exacerbations. Measure FEV1 at start of treatment, after 3–6 months for personal best lung function, then periodically for ongoing risk assessment.

Having uncontrolled asthma symptoms is an important risk factor for exacerbations

Additional potentially modifiable risk factors for exacerbations, even in patients with few asthma symptoms, include:

  • Medications: ICS not prescribed; poor adherence; incorrect inhaler technique; high SABA use (with increased mortality if >1x200-dose canister/month)

  • Comorbidities: obesity; chronic rhinosinusitis; GORD; confirmed food allergy; anxiety; depression; pregnancy

  • Exposures: smoking; allergen exposure if sensitized; air pollution

  • Setting: major socioeconomic problems

  • Lung function: low FEV1, especially if <60% predicted; higher reversibility

  • Other tests: sputum/blood eosinophilia; elevated FeNO in allergic adults on ICS

Other major independent risk factors for flare-ups (exacerbations) include:

  • Ever being intubated or in intensive care for asthma; having ≥1 severe exacerbations in the last 12 months.

Having any of these risk factors increases the patient’s risk of exacerbations even if they have few asthma symptoms

Risk factors for developing fixed airflow limitation include:

  • Preterm birth, low birth weight, greater infant weight gain

  • Lack of ICS treatment

  • Exposures: tobacco smoke, noxious chemicals, occupational exposures

  • Low FEV1

  • Chronic mucus hypersecretion

  • Sputum or blood eosinophilia

 

Risk factors for medication side-effects include:

  • Systemic: frequent OCS; long-term, high dose and/or potent ICS; also taking P450 inhibitors

  • Local: high dose or potent ICS; poor inhaler technique

 

GORD=gastro-oesophageal reflux disease; FeNO=exhaled nitric oxide; ICS=inhaled corticosteroid; OCS=oral corticosteroid; SABA=short-acting b2 -agonist

How to assess asthma control

Asthma control means the extent to which the effects of asthma can be seen in the patient, or have been reduced or removed by treatment. Asthma control has two domains: symptom control and risk factors for future poor outcomes, particularly flare-ups (exacerbations) (see Table 2). Questionnaires like Asthma Control Test and Asthma Control Questionnaire assess only symptom control.

Poor symptom control is a burden to patients and a risk factor for flare-ups. Risk factors are factors that increase the patient’s future risk of having exacerbations (flare-ups), loss of lung function, or medication side-effects.

What is the role of lung function in monitoring asthma?

Once asthma has been diagnosed, lung function is most useful as an indicator of future risk. It should be recorded at diagnosis, three to six months after starting treatment, and periodically thereafter. Most patients should have lung function measured at least every one to two years, more often in children and those at higher risk of flare-ups or lung function decline. Patients who have either few or many symptoms relative to their lung function need more investigation.

How is asthma severity assessed?

Currently, asthma severity is assessed retrospectively from the level of treatment required to control symptoms and exacerbations. Mild asthma is asthma that can be controlled with Step 1 or 2 treatment. Severe asthma is asthma that requires Step 5 treatment. It may appear similar to asthma that is uncontrolled due to lack of treatment.

How to investigate uncontrolled asthma

Most patients can achieve good asthma control with regular controller treatment, but some patients do not, and further investigation is needed.

Algorithm 1 shows the most common problems first, but the steps can be carried out in a different order, depending on resources and clinical context.

Algorithm 1: How to investigate uncontrolled asthma in primary care

How to investigate uncontrolled asthma

Copyright 2020, reprinted with permission, Global Initiative for Asthma, available from www.ginasthma.org

Algorithm 1 shows the most common problems first, but the steps can be carried out in a different order, depending on resources and clinical context.

For further recommendations, refer to the full GINA report

Global Initiative for Asthma. Global strategy for asthma management and prevention—updated 2020. April 2020. www.ginaasthma.org

Published date: 1995

Last updated: April 2020.

GINA ASTHMA STRATEGY 2020