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Asthma

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Updated 2024 GINA guidelines for the diagnosis and management of asthma.

Background

Overview

Definition
Asthma is a chronic disorder of the lower respiratory tract characterized by bronchial hyperresponsiveness and reversible airflow obstruction presenting with episodic or persistent symptoms of wheezing, dyspnea, and cough.
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Pathophysiology
The pathophysiology of asthma is complex and not fully understood. It involves a combination of genetic and environmental factors that lead to airway inflammation, hyperresponsiveness, and remodeling. Exposure to allergens triggers an inflammatory response in the airways, leading to bronchoconstriction, increased mucus production, and airway remodeling.
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Epidemiology
The prevalence of asthma in the US is estimated at 8.2% in the general population involving all ages.
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Risk factors
Risk factors for asthma include a genetic predisposition, atopy, and exposure to environmental factors such as air pollutants and allergens. Additionally, respiratory infections and a personal or family history of allergies are significant risk factors.
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Disease course
The clinical manifestations of asthma include recurrent episodes of wheezing, breathlessness, chest tightness, and coughing. These symptoms can vary in frequency and severity and are often worse at night or in the early morning.
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Prognosis and risk of recurrence
The prognosis of asthma can vary widely among patients. It is generally a controllable chronic condition that can lead to a good QoL with appropriate treatment and lifestyle modifications.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of asthma are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024), the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2024), the European Society for Microbiology and Infectious Diseases (ESCMID 2024), the Global Initiative for Asthma (GINA 2024), the Respiratory Effectiveness ...
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Screening and diagnosis

Indications for screening: as per ERS 2012 guidelines, obtain questionnaire-based identification for surveillance of asthma in all workers at risk of developing work-related asthma.
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  • Diagnostic criteria

Classification and risk stratification

Severity definitions: as per GINA 2024 guidelines, define severe asthma as asthma remaining uncontrolled despite optimized treatment with high-dose ICS-LABA, or requiring high-dose ICS-LABA to prevent it from becoming uncontrolled. Distinguish severe asthma from asthma that is difficult to treat due to inadequate or inappropriate treatment, or persistent problems with adherence or comorbidities, such as chronic rhinosinusitis or obesity.
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Diagnostic investigations

Initial assessment: as per GINA 2024 guidelines, assess symptom control, future risk of adverse outcomes, and treatment issues in adult, adolescent, and pediatric (aged 6-11 years) patients presenting with asthma:
assess symptom control over the last 4 weeks
identify any other risk factors for exacerbations, persistent airflow limitation, or side-effects
measure lung function at diagnosis/initiation of treatment, 3-6 months after starting ICS-containing treatment, then periodically (at least once every 1-2 years), but more often in at-risk patients and patients with severe asthma
document the patient's current treatment step
watch inhaler technique, assess adherence and side-effects
check that the patient has a written asthma action plan
ask about the patient's attitudes and goals for their asthma and medications
assess multimorbidity contributing to symptoms and poor QoL, and sometimes to poor asthma control (such as rhinitis, rhinosinusitis, GERD, obesity, obstructive sleep apnea, depression, and anxiety).
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  • Pulmonary function testing

  • Bronchial challenge testing

  • FeNO testing

  • CBC

  • Serum IgE

  • Procalcitonin

  • Sputum eosinophils

  • Plethysmography

  • Chest CT

  • Screening for occupational exposure

  • Screening for atopy

  • Screening for food allergy

  • Screening for COPD

  • Screening for AAT deficiency

  • Screening for GERD

Medical management

Treatment guidance: as per GINA 2024 guidelines, offer sputum-guided treatment in adult patients with moderate or severe asthma managed in (or referred to) centers experienced in this technique.
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  • Stepwise management

  • Management of mild asthma

  • Adjustment of treatment (assessment)

  • Adjustment of treatment (stepping up)

  • Adjustment of treatment (stepping down)

  • Management of modifiable risk factors

  • Management of exacerbation, self-management

  • Management of exacerbation, primary care setting (evaluation)

  • Management of exacerbation, primary care setting (oxygen therapy)

  • Management of exacerbation, primary care setting (SABAs)

  • Management of exacerbation, primary care setting (oral corticosteroids)

  • Management of exacerbation, primary care setting (ICSs)

  • Management of exacerbation, primary care setting (antibiotics)

  • Management of exacerbation, primary care setting (monitoring and discharge)

  • Management of exacerbation, emergency department setting (evaluation)

  • Management of exacerbation, emergency department setting (SABAs)

  • Management of exacerbation, emergency department setting (systemic corticosteroids)

  • Management of exacerbation, emergency department setting (ICSs)

  • Management of exacerbation, emergency department setting (oxygen therapy)

  • Management of exacerbation, emergency department setting (other treatments)

  • Management of exacerbation, emergency department setting (monitoring and discharge)

  • Allergen immunotherapy

  • Long-term macrolides

  • Biologic therapy

  • Oral corticosteroids

  • Immunosuppressants

Nonpharmacologic interventions

Smoking cessation: as per GINA 2024 guidelines, advise smoking cessation at every visit in patients who smoke or vape. Provide access to counseling and smoking cessation programs if available.
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  • Physical activity

  • Dietary modifications

  • Weight loss

  • Breathing exercises

  • Stress management

  • Vitamin D supplements

  • Avoidance of indoor allergens

  • Avoidance of outdoor allergens

  • Avoidance of weather conditions

  • Avoidance of air pollution

  • Avoidance of occupational exposure

  • Avoidance of exacerbating medications

Therapeutic procedures

Bronchial thermoplasty
As per GINA 2024 guidelines:
Consider offering bronchial thermoplasty, if available, as step 5 in adult patients with uncontrolled asthma despite optimized therapeutic regimens and referral to an asthma specialty center, and not having access to or ineligible for biologic therapy.
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Consider offering add-on treatment with bronchial thermoplasty in selected adult patients with severe asthma.
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Perioperative care

Perioperative management
As per GINA 2024 guidelines:
Ensure achieving good asthma control preoperatively in patients scheduled for elective surgery, especially in patients with more severe asthma, uncontrolled symptoms, exacerbation history, or persistent airflow limitation.
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Weigh the risks of performing surgery without achieving good asthma control against the need for immediate surgery in patients requiring emergency surgery. Administer perioperative hydrocortisone in patients on long-term high-dose ICSs or receiving oral corticosteroids for > 2 weeks during the previous 6 months, because of the risk of adrenal crisis in the context of surgery.
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Specific circumstances

Pediatric patients, diagnosis: as per ERS 2021 guidelines, do not diagnose asthma solely based on symptoms
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or improvement in symptoms after a trial of preventer medication.
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  • Pediatric patients (pulmonary function testing)

  • Pediatric patients (FeNO testing)

  • Pediatric patients (allergen testing)

  • Pediatric patients (bronchial challenge tests)

  • Pediatric patients (indications for treatment)

  • Pediatric patients (treatment guidance)

  • Pediatric patients (stepwise management)

  • Pediatric patients (clinical follow-up)

  • Pediatric patients (pulmonary function monitoring)

  • Pediatric patients (FeNO monitoring)

  • Pediatric patients (laboratory follow-up)

  • Pregnant patients

  • Perimenstrual patients

  • Athletes

  • Patients with exercise-induced bronchoconstriction

  • Patients with aspirin-exacerbated respiratory disease

  • Patients with chronic cough

  • Patients with allergic bronchopulmonary aspergillosis

  • Patients with cardiac arrest

Patient education

Self-management education: as per GINA 2024 guidelines, establish a partnership between the patients with asthma (or the parent/caregiver) and healthcare providers for effective asthma management, and allow the patients to gain the knowledge, confidence, and skills to assume a major role in the management of their asthma. Recognize that self-management education reduces asthma morbidity in both adult and pediatric patients.
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  • Asthma action plans

Preventative measures

Avoidance of occupational exposure: as per ERS 2012 guidelines, eliminate exposure as the best preventive measure to reduce the disease burden of work-related asthma and the preferred approach for primary prevention.
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  • Avoidance of smoke exposure

  • Weight loss

  • Breastfeeding

  • Influenza immunization

Follow-up and surveillance

Indications for specialist referral: as per GINA 2024 guidelines, refer for expert advice in the following cases, where available:
Situation
Guidance
Difficulty confirming the diagnosis of asthma
Symptoms of chronic infection or features suggesting a cardiac or other nonpulmonary cause (immediate referral)
Diagnosis is unclear even after a trial of therapy with inhaled or systemic corticosteroids
Features of both asthma and COPD, and there is doubt about priorities for treatment
Suspected occupational asthma
Refer for confirmatory testing and identification of sensitizing or irritant agent, specific advice about eliminating exposure, and pharmacological treatment
Persistent or severely uncontrolled asthma or frequent exacerbations
Uncontrolled symptoms, ongoing exacerbations, or low lung function despite correct inhaler (medium-dose ICS-LABA) technique and good adherence (identify and treat modifiable risk factors and comorbidities before referral, depending on the clinical context)
Frequent asthma-related healthcare utilization (such as multiple emergency department visits or urgent primary care visits)
Any risk factors for asthma-related death
Near-fatal asthma attack (ICU admission or mechanical ventilation for asthma) at any time in the past
Suspected or confirmed anaphylaxis or food allergy
Evidence of, or risk of, significant treatment side effects
Significant side effects from treatment
Need for long-term oral corticosteroid use
Frequent courses of oral corticosteroids (≥ 2 courses per year)
Symptoms suggesting complications or subtypes of asthma
Aspirin-exacerbated respiratory disease
Allergic bronchopulmonary aspergillosis
Additional reasons for referral in pediatric patients aged 6-11 years
Doubts about the diagnosis of asthma (such as respiratory symptoms not responding well to treatment in a prematurely born child)
Symptoms or exacerbations remain uncontrolled despite medium-dose ICSs with correct inhaler technique and good adherence
Suspected side effects of treatment (such as growth delay)
Concerns about the patient's welfare or well-being
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  • Clinical follow-up

  • Pulmonary function testing follow-up

  • FeNO monitoring

  • Sputum eosinophilia monitoring