Gina's recommendations for bronchial asthma. Bronchial asthma

Mixed asthma (J45.8)

Pulmonology, Pediatric Pulmonology

general information

Short description

Russian Respiratory Society

DEFINITION

Bronchial asthma (BA)- a chronic inflammatory disease of the airways, in which many cells and cellular elements are involved. Chronic inflammation leads to the development of bronchial hyperreactivity, which leads to repeated episodes of wheezing, shortness of breath, chest congestion and coughing, especially at night or in the early morning. These episodes are associated with widespread variable airway obstruction in the lungs, which is often reversible spontaneously or with treatment.

At the same time, it should be emphasized that the diagnosis of asthma is primarily established on the basis of the clinical picture. An important feature is the lack of standardized characteristics of symptoms or laboratory or instrumental studies that would help to accurately establish the diagnosis of bronchial asthma. In this regard, it is impossible to develop evidence-based recommendations for the diagnosis of asthma.

Classification

Determination of the severity of bronchial asthma

Classification of bronchial asthma by severity based on the clinical picture before the start of therapy (Table 6)

STEP 1: Intermittent bronchial asthma

Symptoms less than 1 time per week Short flare-ups Nighttime symptoms no more than twice a month Scatter PSV or FEV1< 20%

STEP 2: Mild persistent bronchial asthma

Symptoms more often than 1 time per week, but less than 1 time per day Flare-ups can impair physical activity and sleep Nocturnal symptoms more than twice a month FEV1 or PSV ≥ 80% of due · Spread of PSV or FEV1 20-30%

STEP 3: Moderate persistent bronchial asthma

Daily symptoms Exacerbations can lead to limited physical activity and sleep disturbance Nighttime symptoms more often than 1 time per week Daily use of inhaled short-acting β2-agonists FEV1 or PSV 60-80% of the due Spread of PSV or FEV1\u003e 30%

STEP 4: Severe persistent bronchial asthma

Daily symptoms Frequent exacerbations Frequent nighttime symptoms Restriction of physical activity FEV1 or PSV ≤ 60% of due Spread of PSV or FEV1\u003e 30%

The classification of the severity of asthma in patients receiving treatment is based on the smallest volume of therapy required to maintain control over the course of the disease. Mild asthma is asthma, the control of which can be achieved with a small amount of therapy (low doses of ICS, antileukotriene drugs, or cromones). Severe asthma is asthma that requires a large amount of therapy to control it (for example, stage 4 or 5, (Fig. 2)), or asthma, which cannot be controlled despite a large amount of therapy.

2 When determining the degree of severity, it is sufficient to have one of the signs of severity: the patient should be attributed to the most severe degree at which any sign occurs. The characteristics noted in this table are general and may overlap, since the course of AD is extremely variable; moreover, over time, the severity of a particular patient may change.

3 Patients with any severity of asthma may have mild, moderate or severe exacerbations. A number of patients with intermittent asthma have severe and life-threatening exacerbations against the background of long asymptomatic periods with normal pulmonary function.

Diagnostics

DIAGNOSTIC PRINCIPLES IN ADULTS AND CHILDREN

Diagnostics:
The diagnosis of asthma is purely clinical and is established on the basis of complaints and anamnestic data of the patient, clinical and functional examination with an assessment of the reversibility of bronchial obstruction, specific allergological examination (skin tests with allergens and / or specific IgE in serum) and exclusion of other diseases (GPP).
The most important diagnostic factor is a thorough collection of anamnesis, which will indicate the causes, duration and resolution of symptoms, the presence of allergic reactions in the patient and his blood relatives, the cause-and-effect features of the onset of signs of the disease and its exacerbations.

Factors influencing the development and manifestations of AD (table 3)

Factors	Description
1. Internal factors	1. Genetic predisposition to atopy 2. Genetic predisposition to BHR (bronchial hyperreactivity) 3. Gender (in childhood BA is more common in boys; in adolescence and adulthood - in women) 4. Obesity
2. Environmental factors	1. Allergens 1.1. Indoors: house dust mites, pet hair and epidermis, cockroach allergens, fungal allergens. 1.2. Outdoors: plant pollen, fungal allergens. 2. Infectious agents (mainly viral) 3. Professional factors 4. Aeropollutants 4.1. External: ozone, sulfur and nitrogen dioxides, combustion products of diesel fuel, etc. 4.2. Inside the home: tobacco smoke (active and passive smoking). 5. Diet (increased intake of highly processed foods, increased intake of omega-6 polyunsaturated fatty acids and reduced intake of antioxidants (in the form of fruits and vegetables) and omega-3 polyunsaturated fatty acids (in fatty fish).

DIAGNOSIS OF BA IN CHILDREN

The diagnosis of bronchial asthma in children is clinical. It is based on monitoring the patient and assessing symptoms while excluding other causes of bronchial obstruction

Diagnostics in different age periods

Clinically during an exacerbation bronchial asthma in children is determined by an obsessive dry or unproductive cough (sometimes up to vomiting), expiratory dyspnea, diffuse dry wheezing in the chest against a background of uneven weakened breathing, chest swelling, boxed tone of percussion sound. Noisy wheezing is heard in the distance. Symptoms may worsen at night or in the early hours of the morning. The clinical symptoms of bronchial asthma change during the day. The entire set of symptoms for the last 3-4 months should be discussed, paying particular attention to those that have been troubling during the previous 2 weeks. Wheezing must be confirmed by a doctor as parents may misinterpret the sounds their child makes when breathing.

Additional diagnostic methods

Examination of the function of external respiration:
. Peak flowmetry (determination of peak expiratory flow rate, PSV) - a method for diagnosing and monitoring the course of asthma in patients over 5 years old. Morning and evening PSV values, daily PSV variability are measured. Daily variability of PSV is defined as the amplitude of PSV between the maximum and minimum values \u200b\u200bduring the day, expressed as a percentage of the average PSV per day and averaged over 2 weeks.

. Spirometry. The assessment of the function of external respiration in conditions of forced expiration can be carried out in children over the age of 5-6 years. A 6-minute jogging protocol is used to detect post-load bronchospasm (high sensitivity but low specificity). Bronchoconstrictor tests are of diagnostic value in some dubious cases during adolescence.

. In the period of remission of bronchial asthma (i.e., in children with a controlled course of the disease), lung function indicators may be slightly reduced or correspond to normal parameters.

Allergic examination

. Skin tests(injection tests) can be performed on children of any age. Since skin tests in young children are less sensitive, a carefully collected history is important.
. Determination of allergen-specific IgE useful in the case when it is not possible to perform skin tests (severe atopic dermatitis / eczema, or it is impossible to stop taking antihistamines, or there is a real threat of an anaphylactic reaction to the introduction of an allergen).
. Inhalation provocative tests withallergens in children they are practically not used.

Other research methods
. In children under 5 years old - computer bronchophonography

. Chest X-ray (to rule out an alternative diagnosis)
. Trial treatment (response to anti-asthma therapy)
. There are no characteristic changes in BA blood tests. Eosinophilia is often detected, but it cannot be considered a pathognomonic symptom
. In the sputum of children with bronchial asthma, eosinophils, Kurshman's spirals can be detected
. The following methods are used in differential diagnosis: bronchoscopy, computed tomography. The patient is referred for specialist consultations (otorhinolaryngologist, gastroenterologist, dermatologist)

Algorithm for the diagnosis of bronchial asthma in children
If bronchial asthma is suspected in children, the emphasis is on the presence of key information in the anamnesis and symptoms on examination with careful exclusion of alternative diagnoses.

High likelihood of asthma

Refer a specialist (pulmonologist, allergist) for consultation Start anti-asthma treatment Assess response to treatment Follow up on unresponsive patients

Low likelihood of asthma

Conduct a more detailed examination

Intermediate likelihood of asthma and proven airway obstruction

Perform spirometry Conduct a test with a bronchodilator (FEV1 or PSV) and / or evaluate the response to trial treatment for the specified period: · If there is significant reversibility or treatment is effective, the diagnosis of asthma is likely. It is necessary to continue to treat asthma, but strive for the minimum effective dose of drugs. Subsequent tactics are aimed at reducing or canceling treatment. · If there is no significant reversibility and trial treatment fails, consider testing to rule out alternative causes.

Intermediate likelihood of asthma without signs of airway obstruction

Children who can have spirometry and have no signs of airway obstruction: Schedule an allergy test Order a reversibility test with a bronchodilator and, if possible, tests for bronchial hyperreactivity with methacholine, exercise or mannitol Send for a specialist consultation

DIAGNOSIS OF BA IN ADULTS

Initial examination:
Diagnosis of asthma is based on the detection of characteristics, symptoms and signs in the absence of an alternative explanation for their occurrence. The main thing is to obtain an accurate clinical picture (history).
Initial diagnosis is based on a careful assessment of symptoms and degree of airway obstruction.
· In patients with a high likelihood of asthma, start trial treatment immediately. Provide additional research in case of insufficient effect.
· In patients with a low likelihood of asthma, whose symptoms are suspected of being the result of another diagnosis, evaluate and treat appropriately. Reconsider the diagnosis in those patients whose treatment does not work.
· The preferred approach for patients with a moderate likelihood of asthma is to continue the evaluation while initiating trial treatment for a period of time until the diagnosis is confirmed and supportive care is determined.

Clinical signs that increase the likelihood of asthma include:
More than one of the following symptoms: wheezing, choking, chest congestion, and coughing, especially if:
- worsening of symptoms at night and early in the morning;
- the occurrence of symptoms during exercise, exposure to allergens and cold air;
- Symptoms after taking aspirin or beta blockers.
· History of atopic diseases;
· The presence of asthma and / or atopic diseases in relatives;
· Widespread dry wheezing when listening (auscultation) of the chest;
Low rates of peak expiratory flow rate or forced expiratory volume in 1 second (retrospectively or in a series of studies), unexplained by other reasons;
· Eosinophilia of peripheral blood, unexplained by other causes.

Clinical signs that decrease the likelihood of having asthma:
· Severe dizziness, darkening of the eyes, paresthesia;
Chronic productive cough in the absence of wheezing or choking;
· Continuous normal chest examinations with symptoms;
· Change of voice;
· The onset of symptoms exclusively against the background of colds;
· A significant history of smoking (more than 20 packs / years);
· Heart disease;
Normal peak expiratory flow rate or spirometry when symptomatic (clinically present).

SPIROMETRY AND REVERSAL TESTS

· Spirometry can confirm the diagnosis when an airway obstruction is detected. However, normal indicators of spirometry (or peak flowmetry) do not exclude the diagnosis of asthma.
· Patients with normal lung function may have an extrapulmonary cause of symptoms, but a bronchodilator test may reveal hidden, reversible bronchial obstruction.
· Tests to detect bronchial hyperresponsiveness (BHR), as well as markers of allergic inflammation, can aid in the diagnosis.
· In adults and children, tests for obstruction, bronchial hyperresponsiveness and airway inflammation may confirm the diagnosis of AD. However, normal values, especially at a time when symptoms are absent, do not rule out the diagnosis of asthma.

Patients with bronchial obstruction
Tests to study the variability of peak expiratory flow rate, lung volumes, gas diffusion, bronchial hyperreactivity and airway inflammation have limited opportunities in the differential diagnosis of patients with bronchial obstruction in asthma and other pulmonary diseases. Patients may have other underlying conditions of the obstruction, making the test difficult to interpret. Asthma and COPD are especially common.

Patients with bronchial obstruction and a moderate likelihood of asthma should undergo a reversibility test and / or trial therapy for a certain period:
If the reversibility test is positive or if a positive effect is achieved during the therapeutic test, the patient should be further treated as a patient with asthma
In case of negative reversibility and the absence of a positive response during a trial course of therapy, further examination should be continued to clarify the diagnosis

Algorithm for examining a patient with suspected AD (Fig. 1).

Therapeutic trials and reversibility tests:

The use of FEV1 or PSV as the main methods for assessing reversibility or response to therapy is more widely used in patients with underlying bronchial obstruction.

Patients with no bronchial obstruction:
In patients with spirometry values \u200b\u200bwithin the normal range, additional research should be carried out to detect bronchial hyperreactivity and / or inflammation of the airways. These tests are quite sensitive, therefore, the normal results obtained during their performance may serve as confirmation of the absence of AD.
Patients without signs of bronchial obstruction and with a moderate likelihood of asthma should be prescribed additional studies before prescribing therapy

Study of bronchial hyperreactivity:
· Tests of bronchial hyperreactivity (BHR) are not widely used in clinical practice. Usually, the detection of GHR is based on measuring the response of the FEV1 indicator in response to inhalation of increasing concentrations of methacholine. The response is calculated as the concentration (or dose) of the provocative agent causing a 20% drop in FEV1 (PC20 or PD20) using linear interpolation of the logarithm of the dose-response curve concentration.
· The distribution of GHR indicators in the population is normal, 90-95% of the healthy population have PK20 values\u003e 8 mg / ml (equivalent to PD20\u003e 4 micromolar). This level has a sensitivity index in the range of 60-100% for the detection of clinically diagnosed asthma.
· In patients with normal pulmonary function, the study of BGR has an advantage over other tests in identifying patients with asthma (Table 4). In contrast, BHR tests play a minor role in patients with established bronchial obstruction, because the specificity of the test is low.
· Other bronchoconstrictor tests used are with indirect provocative agents (mannitol, exercise test). A positive response to these stimuli (i.e., a fall in FEV1 by more than 15%) is a specific indicator of AD. However, these tests are less specific than studies with methacholine and histamine, especially in patients receiving anti-asthma therapy.

Methods for assessing airway inflammation (Table 4)

Test	Norm	Validity
		sensitivity	specificity
Methacholine PK20	\u003e 8 mg / ml	High	Average
Indirect provocation *	Varies	Average #	High
FENO	<25 ppb	High #	Average
Eosinophils in sputum	<2%	High #	Average
PSV variability (% of maximum)	<8** <20%***	Low	Average

PC20 \u003d provocative methacholine concentration causing a 20% drop in FEV1; FENO \u003d exhaled concentration of nitric oxide
*those. provocation by physical activity, inhalation of mannitol;# in untreated patients ; ** if measured twice during the day; *** with more than four measurements

Monitoring PSV:
· The best indicator is recorded after 3 attempts to perform a forced maneuver with a pause not exceeding 2 seconds after inhalation. The maneuver is performed while sitting or standing. More measurements are made if the difference between the two maximum PSV values \u200b\u200bexceeds 40 l / min.
· PSV is used to assess airflow variability in multiple measurements taken over at least 2 weeks. Increased variability can be recorded with two measurements during the day. More frequent measurements improve the score. In this case, an increase in the measurement accuracy is achieved especially in patients with reduced compliance.
· PSV variability is best calculated as the difference between the maximum and minimum values \u200b\u200bas a percentage of the average or maximum daily PSV.
· The upper limit of normal values \u200b\u200bfor variability in% of the maximum indicator is about 20% when using 4 or more measurements during the day. However, it can be lower when using double measurements. Epidemiological studies have shown sensitivity between 19% and 33% for identifying clinically diagnosed asthma.
· The variability of PSV can be increased in diseases with which the differential diagnosis of asthma is most often carried out. Therefore, in clinical practice, there is a lower level of specificity of increased PSV variability than in population studies.
· Frequent registration of PEFs in and out of work is important if a patient is suspected of having occupational asthma. Currently, there are computer programs for the analysis of PSV measurements at and outside the workplace, for the automatic calculation of the effects of occupational exposure.
· PEF values \u200b\u200bshould be interpreted with caution in light of the clinical situation. The PSV study is more useful for monitoring patients with an already established asthma diagnosis than for the initial diagnosis.

Occupational asthma is a disease characterized by the presence of reversible obstruction and / or hyperreactivity of the airways, which are caused by inflammation caused solely by factors of the working environment and in no way associated with irritants outside the workplace.


Classification of occupational asthma:
1) immunoglobulin (Ig) E-conditioned;
2) irritant asthma, including the syndrome of reactive dysfunction of the airways, developed as a result of contact with extremely high concentrations of toxic substances (vapors, gases, smoke);
3) asthma caused by unknown pathogenetic mechanisms.

According to the ERS Guidelines (2012), work-related asthma, or asthma in the workplace, has the following phenotypes:


Fig. 1. Clinical variants of bronchial asthma caused by working conditions
· There are several hundred substances that can cause the development of occupational asthma.
· When inhaled in high doses, some immunologically active sensitizers behave as irritants.
· For anhydrides, acrylates, cimetidine, rosin, enzymes, green coffee and castor beans dust, bakery allergens, pollen, seafood, isocyanates, laboratory animal allergens, piperazine, platinum salts, cedar wood dust, the dose-effect relationship has been proven between the incidence of occupational asthma and the concentration of these substances in the workplace.

Rice

Sensitivity and specificity of diagnostic tests:

Questionnaires for the diagnosis of occupational asthma have high sensitivity but low specificity	1++
Peak expiratory flow (PEF) monitoring has a high degree of sensitivity and specificity for the diagnosis of occupational asthma, if it is carried out at least 4 times during a work shift for 3-4 working weeks with subsequent comparison of indicators on weekends and / or vacation period	1+++
The methacholine test for the detection of NHRP is performed during periods of exposure and elimination of production agents and, as a rule, correlates with the dose of inhaled substances and the worsening of asthma in the workplace.	1+++
The absence of NRHP does not allow excluding the diagnosis of occupational asthma.	1+++
Skin prick tests with industrial hypertension and determination of the level of specific IgE have a high degree of sensitivity for detecting sensitization caused by most agents with VMM	1+++
Specific bronchoprovocation test (SBPT) is the "gold standard" for determining the causative factors (inductors and triggers) of occupational asthma. It is carried out only in specialized centers using exposure cameras when it is impossible to confirm the diagnosis of PA by other methods.	1+++
In the presence of other compelling evidence, a negative PBPT result is not sufficient to rule out occupational asthma.	1++
An increase in the level of eosinophils in induced sputum by more than 1%, with a decrease in FEV1 by more than 20% after SPBT (or going to the workplace after a weekend) can confirm the diagnosis of occupational asthma	1+
The exhaled fraction of nitric oxide correlates with the degree of airway inflammation and the dose of inhaled pollutants in the workplace.	1++

Prognosis and risk factors (endogenous and exogenous) of an unfavorable outcome:

Risk factors for an adverse outcome in occupational asthma at the time of diagnosis: low lung volumes, a high degree of NHRD, or status asthmaticus during SPBT	1++
Further continuation of work in contact with the agent-inducer of PA can lead to an unfavorable outcome of the disease (loss of professional and general disability)	1++
Smoking cessation is favorable for the prognosis of PA	1++
The outcome of occupational asthma does not depend on gender differences	1+++
The presence of concomitant COPD significantly worsens the prognosis of PA	1+++

The role of medical examinations:

Preliminary (upon hiring) and periodic medical examinations within the framework of order No. 302-Н dated 04/12/2011 of the Ministry of Health and Social Development are a key link in preventing the development of occupational asthma, its timely detection and prevention of disability in patients.	1+++
The use of specialized questionnaires allows you to separate workers with a low level of occupational risk from those who need additional research and organizational measures.	1+
Workers with a previously established diagnosis of bronchial asthma have an increased risk of worsening the course of the disease upon contact with industrial aerosols (asthma aggravated by working conditions) up to disability, which should be warned about when hiring.	1+++
A history of atopy does not predict future sensitization to occupational allergens, occupational allergies or asthma	1+++
The combination of various research methods (questionnaire screening, clinical and functional diagnostics, immunological tests, etc.) increases the diagnostic value of a preventive examination	1+++

Step-by-step algorithm for diagnosing occupational asthma:

Figure 2. Algorithm for the diagnosis of occupational asthma.

· When taking an anamnesis from an employee with asthma, it is necessary to find out whether he has contact with adverse factors in the workplace.
Work-related symptoms of allergic asthma can be suspected when at least one of the following criteria is met:
• intensification of symptoms of the disease or their manifestation only at work;
Relief of symptoms on weekends or during the vacation period;
· Regular manifestation of asthmatic reactions after a work shift;
· An increase in symptoms by the end of the working week;
Improvement of well-being, up to the complete disappearance of symptoms, with a change in the nature of the work performed (cessation of contact with causative agents).
For the irritant form of occupational asthma, it is necessary to indicate a history of newly developed asthma-like symptoms within 24 hours after inhalation of irritating gases, vapors, smoke, aerosols in high concentrations with persistence of symptoms from several days to 3 months.
· Methods for the diagnosis of occupational asthma are similar to those for non-occupational asthma.

Management of patients and prevention of occupational asthma:

Drug treatment of PA is unable to prevent its progression in cases of continued work in contact with the causative factor	1+
Timely transfer to work without contact with the causative factor ensures the relief of PA symptoms.	1+++
A decrease in the concentration of agents in the air of the working area can lead to a decrease or relief of PA symptoms. However, this approach is less effective than completely cessation of contact with the etiological factor of asthma.	1++
The use of personal respiratory protection from exposure to industrial aerosols can lead to an improvement in the course of asthma, but not to the complete disappearance of respiratory symptoms and airway obstruction	1++

- The definition, classification, basic concepts and answers to key questions regarding the recommendations for the diagnosis of occupational asthma, given in this section, were formulated by the working group based on the existing recommendations of the British Foundation for Research in Occupational Medicine (British Occupational Health Research Foundation) , American College of Lung Survey (American College of Chest Physicians), manualsAagency for Health and Quality Research (Agency for Healthcare Research and Quality). When describing etiological factors, a meta-analysis of 556 publications on occupational asthma was used byX. Baur (2013).

Prevention

Prevention and rehabilitation of patients with asthma

In a significant proportion of patients, there is a perception that numerous environmental, dietary and other factors can be triggers of asthma, and avoiding these factors can improve the course of the disease and reduce the amount of drug therapy. There is insufficient evidence that it is possible to influence the course of bronchial asthma by non-pharmacological methods and large-scale clinical studies are required.

Key points:
1. Medical treatment of patients with confirmed asthma is a highly effective method of controlling symptoms and improving the quality of life. However, whenever possible, it is necessary to take measures to prevent the development of asthma, asthma symptoms or asthma exacerbation by reducing or eliminating the impact of risk factors.
2. Currently, there are only a small number of measures that can be recommended for the prevention of AD, since the development of this disease involves complex and not fully understood mechanisms.
3. Exacerbation of asthma can be caused by many risk factors, which are sometimes called triggers; these include allergens, viral infections, pollutants and drugs.
4. Reducing the exposure of patients to certain categories of risk factors allows improving AD control and reducing the need for drugs.
5. Early identification of occupational sensitizers and prevention of any subsequent exposure to sensitized patients are important components of occupational AD treatment.

Prospects for primary prevention of bronchial asthma (tab. 10)

	Research results	Recommendations
Elimination of the allergen	The data on the effectiveness of the influence of measures to ensure a hypoallergenic regime inside a home on the likelihood of developing AD are contradictory.	There is insufficient evidence to make a recommendation. 1+
Lactation	There is evidence of a protective effect on the early development of AD	Breastfeeding should be encouraged because of its many benefits. It may play a role in preventing the early development of AD in children
Milk mixtures	There are no studies of sufficient duration on the effect of the use of infant formula on the early development of AD	In the absence of proven benefits of infant formula, there is no reason to recommend their use as a strategy for preventing AD in children. 1+
Nutritional supplements	There is very limited research on the potential protective effects of fish oil, selenium and vitamin E taken during pregnancy	There is insufficient evidence to recommend any supplements to the diet of pregnant women as a means of preventing AD 1+
Immunotherapy (specific immunotherapy)	More studies are needed to confirm the role of immunotherapy in the prevention of AD	There is currently no basis for a recommendation
Microorganisms	Key area for long-term studies to establish efficacy for AD prevention	There is insufficient evidence that the use of probiotics by a mother during pregnancy reduces the risk of asthma in a child.
To give up smoking	Research Finds Associations Between Maternal Smoking and Increased Child's Risk of Disease	Parents and expectant mothers should be advised on the adverse effects of smoking on the child, including the risk of developing AD (Level of Evidence C) 2+

	Research results	Recommendations
Food and additives	Sulfites (preservatives that are often found in drugs and food products such as potato chips, shrimp, dried fruits, beer and wine) are often implicated in the development of severe exacerbations of AD	In the case of proven allergy to a food or food additive, exclusion of this food may lead to a decrease in the frequency of exacerbations of asthma. (Level of EvidenceD)
Obesity	Research shows the relationship between weight gain and AD symptoms	Weight loss is recommended for overweight patients to improve their health and asthma course. (Level of EvidenceB)

Prospects for secondary prevention of asthma (Table 12)

	Research results	Recommendations
Pollutants	Studies show the relationship between air pollution (an increase in the concentration of ozone, nitrogen oxides, acid aerosols and particulate matter) and a worsening BA course.	In patients with controlled asthma, there is usually no need to avoid adverse environmental conditions. Patients with poorly controlled asthma are advised to refrain from intense physical activity in cold weather, with low atmospheric humidity, and a high level of air pollution.
House dust mites	Measures to reduce the concentration of house dust mites help to reduce the number of mites, but there is no evidence of a change in the severity of AD with a decrease in their concentration	In active families, comprehensive measures to reduce the concentration of house dust mites can be helpful.
Pets	There are no well-controlled studies on the reduction of AD severity after removal of pets. However, if there is a BA patient in the family, you should not have a pet	There is no reason to recommend
Smoking	Active and passive smoking has a negative impact on quality of life, lung function, the need for emergency medications and long-term monitoring with the use of inhaled steroids	Patients and their families need to be explained the dangers of smoking for BA patients and provide assistance in quitting smoking. (Level of Evidence C) 2+
Allergen-specific immunotherapy	Specific immunotherapy has a positive effect on the course of asthma.	The need for immunotherapy should be considered in patients with AD when it is impossible to avoid exposure to a clinically significant allergen. It is necessary to inform the patient about the possibility of serious allergic reactions to immunotherapy (Evidence level B) 1 ++

Alternative and alternative medicine (Table 13)

	Research results	Recommendations
Acupuncture, Chinese medicine, homeopathy, hypnosis, relaxation techniques, air ionizers.	There is no evidence of a positive clinical effect on the course of asthma and improvement of lung function	Insufficient evidence to make a recommendation. Air ionizers are not recommended for AD treatment (Level of Evidence A)	1++
Breathing according to the Buteyko method	Respiratory technique aimed at controlling hyperventilation. Studies have shown the possibility of some reduction in symptoms and inhalation of bronchodilators, but without affecting lung function and inflammation	May be considered as an adjuvant in reducing the level of perception of symptoms (Level of Evidence B)

Education and training of patients with asthma (Table 14)

	Research results	Recommendations
Patient education	The training is based on the presentation of the necessary information about the disease, the preparation of an individual treatment plan for the patient, and training in the technique of guided self-behavior.	It is necessary to train BA patients in basic techniques for monitoring their condition, adherence to an individual action plan, and conduct a regular assessment of the condition by a doctor. At each stage of treatment (hospitalization, repeated consultations), the patient's managed self-behavior plan is revised. (Evidence level A) 1+
Physical rehabilitation	Physical rehabilitation improves cardiopulmonary function. As a result of exercise during physical activity, the maximum oxygen consumption increases and the maximum ventilation of the lungs increases.	There is not enough evidence base. According to the available observations, the use of training with aerobic load, swimming, training of inspiratory muscles with a threshold dosed load improves the course of asthma.

Information

Sources and Literature

1. Clinical guidelines of the Russian Respiratory Society

Information

Chuchalin Alexander Grigorievich	Director of the Research Institute of Pulmonology of the FMBA, Chairman of the Board of the Russian Respiratory Society, chief freelance specialist pulmonologist of the Ministry of Health of the Russian Federation, academician of the Russian Academy of Medical Sciences, Professor, Doctor of Medical Sciences
Aisanov Zaurbek Ramazanovich	Head of the Department of Clinical Physiology and Clinical Research, Research Institute of Pulmonology, FMBA, Professor, Doctor of Medical Sciences
Belevsky Andrey Stanislavovich	Professor of the Department of Pulmonology, FUV RNIMU named after N.I. Pirogov, chief freelance specialist-pulmonologist of the Moscow Department of Health, Professor, Doctor of Medical Sciences
Bushmanov Andrey Yurievich	doctor of Medical Sciences, Professor, Chief Freelance Specialist, Occupational Pathologist of the Ministry of Health of Russia, Head of the Department of Hygiene and Occupational Pathology of the Institute of Postgraduate Professional Education of the Federal State Budgetary Institution SSC FMBC named after A.I. Burnazyan FMBA of Russia
Vasilyeva Olga Sergeevna	doctor of Medical Sciences, Head of the Laboratory of Ecological-Dependent and Occupational Pulmonary Diseases of the Federal State Budgetary Institution "Scientific Research Institute of Pulmonology" of the FMBA of Russia
Volkov Igor Konstantinovich	Professor of the Department of Children's Diseases, Faculty of General Medicine 1, Moscow State Medical University I.M.Sechenova, professor, doctor of medical sciences
Geppe Natalia Anatolyevna	Head of the Department of Pediatric Diseases, Faculty of General Medicine 1, Moscow State Medical University. I.M.Sechenova, professor, doctor of medical sciences
Prince Nadezhda Pavlovna	Associate Professor of the Department of Pulmonology, FUV Russian National Research Medical University named after N.I. Pirogova, Associate Professor, Ph.D.
Mazitova Nailya Nailevna	doctor of Medical Sciences, Professor of the Department of Occupational Medicine, Hygiene and Occupational Pathology of the Institute of Postgraduate Professional Education of the Federal State Budgetary Institution State Research Center FMBC named after A.I. Burnazyan FMBA of Russia
Meshcheryakova Natalia Nikolaevna	Leading Researcher, Laboratory of Rehabilitation, Research Institute of Pulmonology, FMBA, Ph.D.
Nenasheva Natalia Mikhailovna	Professor of the Department of Clinical Allergology of the Russian Medical Academy of Postgraduate Education, Professor, Doctor of Medical Sciences
Revyakina Vera Afanasyevna	Head of the Department of Allergology, Research Institute of Nutrition, Russian Academy of Medical Sciences, Professor, Doctor of Medical Sciences
Shubin Igor Vladimirovich	Chief Physician of the Military Medical Directorate of the Main Command of the Internal Troops of the Ministry of Internal Affairs of Russia, Ph.D.

METHODOLOGY

Methods used to collect / select evidence:
search in electronic databases.

Description of methods used to collect / select evidence:
The evidence base for the recommendations is the publications included in the Cochrane Library, EMBASE and MEDLINE databases. The search depth was 5 years.

Methods used to assess the quality and strength of evidence:
· Consensus of experts;
· Assessment of significance in accordance with the rating scheme (the scheme is attached).

Evidence levels	Description
1++	High quality meta-analyzes, systematic reviews of randomized controlled trials (RCTs) or RCTs with very low risk of bias
1+	Well-conducted meta-analyzes, systematic, or RCTs with low risk of bias
1-	Meta-analyzes, systematic, or RCTs with high risk of bias
2++	High quality systematic reviews of case-control studies or cohort studies. High-quality reviews of case-control studies or cohort studies with very low risk of confounding effects or bias and medium likelihood of causality
2+	Well-conducted case-control or cohort studies with an average risk of confounding effects or bias and an average likelihood of a causal relationship
2-	Case-control or cohort studies with a high risk of confounding effects or bias and an average likelihood of a causal relationship
3	Non-analytical studies (eg: case reports, case series)
4	Expert opinion

Methods used to analyze evidence:
· Reviews of published meta-analyzes;
· Systematic reviews with tables of evidence.

Description of the methods used to analyze the evidence:
In selecting publications as potential sources of evidence, the methodology used in each study is examined to ensure that it is valid. The outcome of the study affects the level of evidence assigned to a publication, which in turn affects the strength of the recommendations that follow from it.
The assessment process can undoubtedly be influenced by the subjective factor. To minimize potential errors, each study was assessed independently, i.e. at least two independent members of the working group. Any differences in assessments were already discussed by the whole group as a whole. If it was impossible to reach a consensus, an independent expert was involved.

Evidence tables:
Evidence tables were completed by members of the working group.

The methods used to formulate the recommendations:
Expert consensus.

Power	Description
AND	At least one meta-analysis, systematic review or RCT rated 1 ++ that is directly applicable to the target population and demonstrates robustness of the results or a group of evidence including research results rated 1+ that are directly applicable to the target population and demonstrating overall robustness of the results
IN	A pool of evidence including study results rated 2 ++, directly applicable to the target population and demonstrating overall robustness of the results or extrapolated evidence from studies rated 1 ++ or 1+
FROM	A pool of evidence that includes research results rated 2+ that are directly applicable to the target population and demonstrate overall robustness of the results; or extrapolated evidence from studies rated 2 ++
D	Level 3 or 4 proof; or extrapolated evidence from studies rated 2+

Good practice indicators (Good Practice Points - GPPs):
Recommended Good Practice is based on the clinical experience of the members of the Guidelines Development Working Group.

Economic analysis:
No cost analysis was carried out and pharmacoeconomics publications were not analyzed.

Description of the recommendation validation method:
These guidelines have been peer-reviewed by peer reviewers in draft versions, who were asked to comment primarily on the extent to which the interpretation of the evidence underlying the guidelines is understandable.
Comments were received from primary care physicians and district therapists regarding the clarity of the presentation of recommendations and their assessment of the importance of the recommendations as a working tool of daily practice.
The draft was also sent to a non-medical reviewer for comments from a patient perspective.

Each patient diagnosed with bronchial asthma is registered in the clinic, where his medical record is kept, which allows him to control the treatment of asthmatic attacks and keep statistics of changes in the patient's condition. The history of bronchial asthma is described in a special diary. It starts with the person's passport data and contains information about the initial manifestations of the diagnosis, complaints, frequency of seizures and diagnosis.

All medical records are kept in the archive of the hospital for another 25 years after discharge. Therefore, each new specialist can see a report on the work done by the doctors who previously treated the patient - therapist, allergist, pulmonologist. For therapeutic procedures, the type of asthma is initially determined - allergic, non-allergic or mixed, and the degree of its severity.

Forms of bronchial asthma

• Allergic bronchial asthma. A history of asthma in this form often develops from childhood, and is caused by the course of diseases such as atopic dermatitis or allergic rhinitis. Moreover, heredity in this case plays a significant role - if close relatives suffered from asthma, then the risk of developing the disease in a child increases. Allergic asthma is the easiest to recognize. Before starting treatment, it is necessary to examine the induced sputum to detect airway inflammation. Patients with this phenotype of the disease have a good response to inhalation with corticosteroids.

• Non-allergic bronchial asthma... This phenotype can result from exposure to medications, as is the case with aspirin asthma. Also, the development of the disease can occur against the background of hormonal changes in the body of women, for example, during the bearing of a child.

To begin adequate treatment for a mixed form of the disease, it is necessary to study the patient's complaints, learn about the time and conditions of the first attack. You need to find out what medications were used to suppress the attack, and how effective the prescribed treatment was.

A medical history of bronchial asthma, mixed form, may contain the following information:

• Complaints: Sharp attacks of suffocation, repeated several times a day. At night, there is an increase in shortness of breath. Symptoms disappear completely after taking beta-agonists. After an attack of suffocation, a short-term cough begins with sputum discharge.
• Primary onset of symptoms: The first attack happened unexpectedly, during a trip in a crowded trolleybus. The patient could not fully inhale air, and shortness of breath began. After he went outside, the symptoms disappeared after 15 minutes. Subsequently, the symptoms began to recur 1-2 times a month under various conditions. The patient was in no hurry to see a doctor, because he believed that the cause of such symptoms was bronchitis, and he treated himself.
• Factors provoking the onset of the disease: bad habits, place of work and the degree of harmfulness of working conditions, food addictions, previous illnesses, allergic reactions, heredity.
• General examination of the patient: patient's physique, condition of nails, hair, skin, mucous membranes. The condition of the lymph nodes and tonsils is taken into account. The musculoskeletal system is being studied: joint mobility, problems with the spine. The most thoroughly studied is the respiratory and cardiovascular systems.

An integrated approach will allow you to identify what exactly provokes breathing problems and, on this basis, make the correct diagnosis. The mixed form of asthma is characterized by frequent attacks of suffocation, shortness of breath with hoarseness. More often, the development of such a disease is facilitated by a hereditary factor.

Determination of the severity of bronchial asthma

For the successful diagnosis of the disease, a clinical picture is drawn up with the study of characteristics, symptoms and signs that are not characteristic of other diseases. The medical history for the treatment of bronchial asthma begins with an initial diagnosis, in which the doctor assesses the degree of airway obstruction. If the likelihood of asthma is high, it is necessary to immediately start trial treatment, and then, in the absence of the effect of therapy, prescribe additional studies.

With a low to moderate likelihood of asthma, the characteristic symptoms may be due to a different diagnosis.

There are 4 stages in the development of the disease:

1. Intermittent asthma - the safest stage of the disease. Short attacks are rare, no more than once a week. At night, exacerbations are even less common.
2. Mild persistent asthma - attacks occur more often than once a week, but only once a day. At night, 2-3 attacks occur per month. Along with shortness of breath, sleep disturbance and decreased physical activity occur.
3. Moderate persistent asthma - the disease makes itself felt every day with acute attacks. Nocturnal manifestations are also more frequent, and appear more often than once a week.
4. Severe persistent asthma... The attacks are repeated daily, at night it reaches several cases a week. Sleep problems - the patient is tormented by insomnia, physical activity. too difficult.

A patient, regardless of the severity of the disease, may experience mild, moderate and severe exacerbations. Even a patient with intermittent asthma can have life-threatening attacks after a long time without any symptoms.

The severity of the patient's condition is not static, and can change over the years.

Treatment and clinical guidelines

After the patient has been assigned asthmatic status, the attending physician prescribes clinical recommendations for treatment. Depending on the form and stage of the course of the disease, the following methods can be used:

• Drug therapy aimed at maintaining the work of the bronchi, preventing inflammation, treating symptoms, stopping attacks of suffocation.
• Isolation of the patient from conditions that cause deterioration (allergens, harmful working conditions, etc.).
• A diet that excludes fatty, salty, junk food.
• Measures to improve and strengthen the body.

With the drug treatment of asthma, only symptomatic drugs should not be used, since the body gets used to it and stops responding to active ingredients. Thus, against the background of the development of pathological processes in the bronchi, treatment stops flowing, which negatively affects the dynamics, postponing complete recovery.

There are 3 main groups of drugs that are used in the treatment and relief of asthma attacks:

• emergency aid - they provide quick help in case of choking;
• basic drugs;
• control drugs.

All treatment is aimed at reducing the frequency of attacks and minimizing possible complications.

GLOBAL STRATEGY FOR

ASTHMA MANAGEMENT AND PREVENTION

Global Strategy for Asthma Management and Prevention The GINA reports are available on www.ginasthma.org.

GLOBAL BRONCHIAL ASTHMA TREATMENT AND PREVENTION STRATEGY

Revision 2014

Translation from English

Moscow Russian Respiratory Society

BBK 54.12 G52

UDC 616.23 + 616.24

D52 Global strategy for the treatment and prevention of bronchial asthma (2014 revision) / Per. from English. ed. A.S. Belevsky. - M .: Russian Respiratory Society, 2015 .-- 148 p., Ill.

The publication is a Report of the GINA (Global Initiative for Asthma) Working Group - revision of 2014. The new version of the fundamentally revised Report is better structured and more convenient for practical use, contributing to better diagnostics and more effective treatment of bronchial asthma (BA). A new definition of the disease has been given, the section on BA diagnosis has been substantially updated. Detailed algorithms for primary diagnosis and prescription of initial therapy in patients with newly diagnosed asthma are presented. New chapters have appeared on the differential diagnosis of asthma, chronic obstructive pulmonary disease (COPD), and asthma-COPD overlapping syndrome, as well as the diagnosis and treatment of asthma patients under 5 years of age.

For pulmonologists, allergists, therapists, pediatricians, general practitioners, health authorities.

© Global Initiative for Asthma, all rights reserved. Use is by express license from the owner, 2014

© Translation into Russian, Russian Respiratory Society, 2015

Global strategy for the treatment and prevention of bronchial asthma (revised 2014)

GINA BOARD *

J. Mark FitzGerald, MD, Chair

Vancouver, BC, Canada

Eric D. Bateman, MD

Cape Town, South Africa

Louis-Philippe Boulet, MD

Université Laval

Québec, QC, Canada

Alvaro A. Cruz, MD

Federal University of Bahia

Salvador, BA, Brazil

Tari Haahtela, MD

Helsinki University Central Hospital

Helsinki, Finland

Mark L. Levy, MD

The University of Edinburgh

Paul O'Byrne, MD

McMaster University

Hamilton, ON, Canada

Pierluigi Paggiaro, MD

University of Pisa

Soren Erik Pedersen, MD

Kolding hospital

Kolding, Denmark

Manuel Soto-Quiroz, MD

Hospital Nacional de Niños

San José, Costa Rica

Helen K. Reddel, MBBS PhD

Sydney, Australia

Gary W. Wong, MD

Chinese University of Hong Kong

SCIENTIFIC COMMITTEE GINA *

Helen K. Reddel, MBBS PhD, Chair

Woolcock Institute of Medical Research

Sydney, Australia

Neil Barnes, MD (to May 2013)

London Chest Hospital

Peter J. Barnes, MD (to Dec 2012)

National Heart and Lung Institute

Eric D. Bateman, MD

University of Cape Town Lung Institute

Cape Town, South Africa

Allan Becker, MD

University of Manitoba

Winnipeg, MB, Canada

Elisabeth Bel, MD (to May 2013)

University of Amsterdam

Amsterdam, The Netherlands

Johan C. de Jongste, MD PhD Erasmus University Medical Center Rotterdam, The Netherlands

Jeffrey M. Drazen, MD

Harvard Medical School

J. Mark FitzGerald, MD

University of British Columbia

Vancouver, BC, Canada

Hiromasa Inoue, MD

Kagoshima University

Kagoshima, Japan

Robert F. Lemanske, Jr., MD

University of Wisconsin

Madison, WI, USA

Paul O'Byrne, MD

McMaster University

Hamilton, ON, Canada

Ken Ohta, MD PhD (to May 2012)

National Hospital Organization Tokyo

National Hospital

Soren Erik Pedersen, MD

Kolding hospital

Kolding, Denmark

Emilio Pizzichini, MD

Universidade Federal de Santa Catarina Florianópolis, SC, Brazil

Stanley J. Szefler, MD

Children’s Hospital Colorado

Sally E. Wenzel, MD (to May 2012)

University of Pittsburgh

Pittsburgh, PA, USA

Brian Rowe, MD MSc (Consultant to Science Committee)

University of Alberta Edmonton, AL, Canada

EXTERNAL REVIEWERS

Mary Ip, MBBS MD

University of Hong Kong Pokfulam

Richmond Hill, ON, Canada

Huib Kerstjens, MD PhD

University of Groningen

Groningen, The Netherlands

Mike Thomas, MBBS PhD

University of Southampton

Thys van der Molen, MD

University of Groningen

Groningen, The Netherlands

Monica Federico, MD

Children’s Hospital Colorado

You should refer to this publication as follows:

Global Bronchial Asthma Initiative. Global strategy for the treatment and prevention of bronchial asthma (revised 2014).

The document is available at www.ginasthma.org.

* For more information on GINA Board and Scientific Committee members, visit www.ginasthma.com

GINA ASSEMBLY MEMBERS

	Richard Beasley, MBChB DSc	Patrick Manning, MD
	Medical Research Institute of New	St. James' Hospital
	Wellington, New Zealand
		Yousser Mohammad, MD
	Carlos Baena Cagnani, MD	Tishreen University School of Medicine
	Catholic University of Córdoba
	C`ordoba, Argentina
		Hugo E. Neffen, MD
		Clinica Alergia E Immunologie
	Children’s Hospital of the Capital	Santa Fe, Argentina
		Ewa Nizankowska-Mogilnicka, MD
	Maia Gotua, MD PhD	University School of Medicine
	Center of Allergy & Immunology
	Republic of Georgia
	Carlos Adrian Jiménez	Petr Pohunek, MD PhD
		University Hospital Motol
	San Luis Potosí, México
		Gustavo Rodrigo, MD
	Ghent University Hospital	Hospital Central de las Fuerzas
		Armadas, Montevideo, Uruguay
	Aziz Koleilat, MD	Joaquin Sastre, MD PhD
	Makassed hospital	Universidad Autonoma de Madrid
	Le Thi Tuyet Lan, MD PhD	Wan-Cheng Tan, MD
	University of Pharmacy and Medicine	iCAPTURE Center for Cardiovascular
	Ho Chi Minh City, Vietnam	and Pulmonary Research
		Vancouver, BC, Canada
	Jorg D. Leuppi, MD PhD
	University Hospital
	Basel, Switzerland
		GINA PROGRAM
	National University Hospital	Suzanne Hurd, PhD
		Scientific Director
	Eva Mantzouranis, MD
	University Hospital
	Heraklion, Crete, Greece

OTHER PARTICIPANTS

William Kelly, PharmD

University of New Mexico

Albuquerque, NM, USA

Christine Jenkins, MD

The george institute

Sydney, Australia

Stephen Lazarus, MD

University of California San Francisco

San Francisco, CA, USA

Gregory Moullec PhD

University of British Columbia

Vancouver, BC, Canada

Marielle Pijnenburg, MD PhD

Erasmus MC-Sophia Children’s Hospital

Rotterdam, The Netherlands

Mohsen Sadatsafavi, MD PhD

University of British Columbia

Vancouver, BC, Canada

D. Robin Taylor, MD DSc

Wishaw General Hospital

Johanna van Gaalen, MD Leiden University Medical Center Leiden, The Netherlands

OTHER ASSISTANCE

Beejal Viyas-Price

Preface to Russian translation

Dear Colleagues!

Here is the translation into Russian of the new version of the Report of the working group of the international program GINA - "Global strategy for the treatment and prevention of bronchial asthma" (revision 2014). This version contains a number of significant changes and additions that are extremely important to consider when managing patients with bronchial asthma (BA). The report contains a large number of summary tables and algorithms for the management of patients with asthma, which simplifies the implementation of the recommendations presented in clinical practice.

Changes in the report are already visible from the definition of BA. The new version emphasizes that AD is a heterogeneous disease; five most common phenotypes of the disease are identified.

IN the chapter devoted to the diagnosis of AD, detailed algorithms for primary diagnosis appeared, including

at patients already receiving anti-asthma therapy. In this section, clinical and functional criteria are clearly formulated, both confirming the diagnosis of AD and reducing its likelihood. The authors of the document additionally highlighted the diagnostic features of BA in pregnant women, athletes and people with obesity, presented in a convenient form information on differential diagnostics in different age groups. Thus, the updated section on BA diagnostics contains a number of additions; in addition, it is now better structured and more convenient for practical use.

IN the new version of the document retains the concept of “BA control” as control over clinical symptoms and the risk of adverse events in the future. Risk factors for the development of exacerbations, irreversible bronchial obstruction and side effects from drug therapy are described in more detail, as well as the role of assessing the function of external respiration in the management of BA patients. The GINA recommendations from 2014 emphasize the need for continuous monitoring of the course of asthma and risk factors for the progression of the disease and its exacerbations.

An integral condition for effective cooperation between a doctor and a patient is building partnerships, conducting educational programs and an individual approach to each BA patient. To improve the effectiveness of inhalation therapy, the guideline recommends taking into account the lifestyle, age, emotional state and preferences of the patient. It is extremely important to teach BA patients the skills of self-management, to draw up an individual action plan for them, including in the case of an exacerbation that begins.

IN the section on the treatment of asthma, in comparison with other versions of GINA, pays more attention to prescribing therapy in patients with newly diagnosed asthma. The manual provides a detailed algorithm for prescribing initial therapy in these patients. It is recommended to prescribe inhaled glucocorticosteroids already at the first stage of treatment in the presence of certain risk factors.

A significant change is that this version of the Report has new chapters devoted to the differential diagnosis of asthma, chronic obstructive pulmonary disease (COPD), and asthma-COPD overlap syndrome, as well as the diagnosis and treatment of asthma patients under 5 years of age. These chapters are extremely important for clinical practice, and their inclusion in a single document significantly expands the scope of its use.

Thus, the new version of GINA contains a number of significant changes aimed at improving the diagnosis and increasing the effectiveness of AD treatment. The information presented is well structured and clearly illustrated, which simplifies its practical use.

A.S. Belevsky, professor

Translation editor, member of the board of the Russian Respiratory Society, R.N. N.I. Pirogov, Moscow, Russia

Foreword

Bronchial asthma (BA) is a serious global health problem that affects all age groups. In many countries, the prevalence of AD is increasing, especially among children. Although AD hospitalizations and deaths have declined in some countries, the disease still causes unacceptably high damage to the health care system and society through lost productivity in the workplace and family distress (especially when it comes to AD in children).

In 1993, the National Institute of Heart, Lung and Blood (NIHLB, USA) together with the World Health Organization (WHO) created a working group, the result of which was the report "Global strategy for the treatment and prevention of bronchial asthma." This was followed by the creation of the Global Initiative for Asthma (GINA) - a network structure for the interaction of doctors, hospitals and government agencies in order to disseminate information about approaches to treating patients with asthma, as well as to ensure the functioning mechanism for introducing scientifically proven research results into improved BA treatment standards Later, the GINA Assembly was created, which included specially attracted experts in the treatment of AD from many countries. To facilitate international cooperation and dissemination of information on BA, the Assembly works with the Scientific Committee, Board members and the Committee on the dissemination and implementation of the GINA recommendations. The GINA (Global Strategy for the Treatment and Prevention of Bronchial Asthma) report has been updated annually since 2002. Publications based on the GINA reports have been translated into many languages. In 2001, GINA initiated the annual World Asthma Day, which aims to raise awareness of the damage caused by asthma, as well as organizing local and national events aimed at educating patient families and healthcare professionals about effective methods of BA control and treatment.

Despite all the efforts made, as well as the availability of effective treatment methods, data from international studies still indicate an insufficient level of AD control in many countries. Since the goal of the recommendations in this Report is to improve the treatment of BA patients, it is necessary to do everything possible to ensure that healthcare organizers ensure the availability and accessibility of medicines and develop methods for introducing effective BA treatment programs and assessing their results.

By 2012, the specialists' awareness of the heterogeneous nature of AD increased, the existence of a spectrum of chronic respiratory diseases was recognized, the understanding of the key role of patient adherence to the prescribed treatment and their awareness of health issues increased, and interest in the individualization of AD treatment increased. In addition, a solid evidence base has emerged regarding effective methods for implementing clinical guidelines. These aspects suggested that a simple statement of the basic principles of AD treatment was not enough: the recommendations had to be combined into strategies that would be clinically significant and suitable for implementation in daily clinical practice. To this end, the recommendations of the 2014 GINA Report are presented in a user-friendly manner, with extensive use of pivot tables and figures. The report also includes two new chapters, one of which is devoted to the treatment of asthma in children aged 0 to 5 years (previously published separately), and the second contains information on such an important topic as the diagnosis of BA – COPD overlap syndrome (SPBAC). The last of these chapters is published in conjunction with the Global Strategy for the Diagnosis, Management, and Prevention of COPD, GOLD. For ease of reference, guidelines for clinical practice are provided in the main GINA Report, and annexes containing supporting reference material are available online (www.ginasthma.org).

It is a great honor for us to acknowledge the excellent work of all those who contributed to the successful completion of the GINA program, as well as the large number of people who participated in this draft update of the Report. This work, along with GINA's revenue from the sale of materials based on the Report, was supported by unlimited educational grants from various companies (listed at the end of the report). However, the responsibility for the statements and conclusions presented in this publication rests entirely with the members of the GINA committees. They receive no honoraria or reimbursement of expenses incurred in the process of attending scientific review conferences held twice a year, as well as for the many hours spent browsing the literature, and significant contributions to the writing of the Report.

We hope that the updated Report will serve you as a useful source of information on asthma treatment methods and that when using it, you will realize the need to apply an individual approach to the treatment of absolutely all asthma patients who will meet in your practice.

J. Mark FitzGerald, MD	Helen K. Reddel, MBBS PhD
Chair, GINA Board of Directors	Chair, GINA Science Committee

	List of figures
Figure: 1-1. Scheme of primary diagnosis of asthma for clinical practice ........................................... .................................................. ....................
Figure: 2-1. Evaluation of a patient with poor symptom control and / or exacerbations despite treatment ..........................
Figure: 3-1. Control-based BA treatment cycle ........................................... .................................................. ...............................................
Figure: 3-2. A stepwise approach to prescribing therapy aimed at controlling symptoms and minimizing future risk ...
Figure: 4-1. Self-behavior during BA exacerbation in adults and adolescents using a written action plan for BA .............................
Figure: 4-2. Treatment of BA exacerbations in general medical practice ........................................... .................................................. ...............................
Figure: 4-3. Treatment of exacerbations of asthma in the setting of emergency medical care, for example, in the emergency department ..........
Figure: 6-1. Probability of BA diagnosis or response to BA therapy in children 5 years of age and younger .................................... .................................................. ..
Figure: 6-2. A stepwise approach to long-term BA treatment in children aged 5 years and younger .................................... .....................................
Figure: 8-1. Approach to the implementation of the "Global strategy for the treatment and prevention of bronchial asthma" ...................................... .........................
	List of tables
Table 1-1.	Diagnostic criteria for BA in adults, adolescents and children aged 6–11 years ................................... ...................................
Table 1-2.	Differential diagnosis of asthma in adults, adolescents and children aged 6–11 years ................................... .........................
Table 1-3.	Confirmation of the diagnosis of asthma in a patient who is already receiving therapy aimed at disease control ......................
Table 1-4.	How to reduce the intensity of therapy aimed at controlling the disease, if it is necessary to confirm the diagnosis of AD ...
Table 2-1.	BA assessment in adults, adolescents and children aged 6–11 years .................................... .................................................. ..............
Table 2-2.	Assessment of BA control in adults, adolescents and children aged 6–11 years, developed by GINA ................................ ....................
Table 2-3.	Special questions for assessing BA in children aged 6–11 years ..................................... .................................................. .........
Table 3-1.	Communication strategies for healthcare professionals ............................................. .................................................. ..........
Table 3-2.	Decision-making on BA treatment at the population level versus the individual level ..................................... ....
Table 3-3.
Table 3-4.	Low, medium and high daily doses of ICS .......................................... .................................................. ...............................
Table 3-5.	Options for reducing the intensity of therapy in well-controlled BA .......................................... .....................................
Table 3-6.	Impact on modifiable risk factors to reduce the risk of exacerbations ......................................... .............................
Table 3-7.	Non-pharmacological interventions - an overview ............................................. .................................................. .....................
Table 3-8.	Indications for assessing the need for referral to a specialist consultation, if possible .....................
Table 3-9.	Strategies for effective use of inhalers ............................................ ................................................
Table 3-10.	Unsatisfactory adherence to therapy in AD ............................................. .................................................. ................
Table 3-11.	Information about the BA ............................................... .................................................. .................................................. .......................
Table 3-12.	Examination and treatment in severe asthma ............................................ .................................................. ........................................
Table 4-1.	Factors increasing the risk of death associated with asthma ......................................... .................................................. .......
Table 4-2.	Organization of discharge after hospitalization or treatment in the emergency department for asthma ...................................
Table 5-1.	Current definitions of asthma, COPD and clinical description of SPBAC ......................................... .................................................. .......
Table 5-2a.	Signs typical for BA, COPD and SPBAC ......................................... .................................................. ...................................
Table 5-2b.	Signs characteristic of AD or COPD ........................................... .................................................. .........................................
Table 5-3.	Spirometry indices in BA, COPD and SPBAC .......................................... .................................................. ..............................
Table 5-4.	Summary of the syndromic approach to chronic airflow restriction diseases ...
Table 5-5.	Specialized research methods that can be used for the differential diagnosis of BA and COPD ...
Table 6-1.	Characteristics for suspecting BA in children aged 5 years and under ..................................... ................................
Table 6-2.	Common differential diagnoses for AD in children aged 5 years and under ..................................... .................
Table 6-3.	Assessment of BA control in children aged 5 years and younger according to GINA ..................................... .................................................. ...........
Table 6-4.	Low daily doses of ICS in children aged 5 years and younger ...................................... .................................................. .....
Table 6-5.	Choosing an inhalation device for children aged 5 years and under ....................................... .............................................
Table 6-6.	Initial assessment of asthma exacerbation in children 5 years of age and younger ........................................ .................................................. .........
Table 6-7.	Indications for immediate hospitalization in children aged 5 years and under ...................................... ..................................
Table 6-8.	Initial treatment of BA exacerbations in children aged 5 years and under ...................................... ..................................................
Table 7-1.
Table 8-1.	Essential elements for implementing a health strategy ........................................ ...............
Table 8-2.	Examples of barriers to implementation of evidence-based recommendations ............................................ .................................................. ...

Bronchial asthma (BA) is a chronic lung disease of an allergic nature. With bronchial asthma, recommendations for treatment are necessary in the same way as consulting an allergist. Choking attacks occur with stress, inflammation, or allergic agents.

The cause of the development of this disease has not yet been clarified, but it is possible to control the occurrence of seizures. By following the doctor's recommendations, you will maintain an active lifestyle, even such a serious disease as asthma is treatable.

The goal of fruitful treatment of BA patients is:

• complete elimination of seizures and prevention of manifestations of the disease;
• improving the quality of life;
• reducing the need for the use of β 2 - agonists;
• maintaining normal lung function;
• prevention of exacerbations;
• reducing the risk of side effects of the therapy.

Drug therapy

The basis for maintaining a long seizure-free period is taking medications.

N.B. You cannot select medicines yourself, only a doctor can prescribe them!

The drugs are classified into two types:

• immediate action;
• prolonged action.

The former are used to quickly relieve symptoms. These include sprays and aerosols, which reach the bronchi as quickly as possible and have a bronchodilatory effect. Nebulizers can be used for children. They have a finer spray than inhalers and deliver the drug to the lungs much faster.

Sustained-release drugs are taken daily for moderate and severe asthma. The therapy is divided into stages depending on the severity. Severity is measured by the number of seizures during the month, as well as the presence of nocturnal seizures. If exacerbations occur at least 2 times during a month or 1 time at night, it is recommended to start treatment with low-dose hormonal drugs - glucocorticoids.

If therapy does not give a significant reduction in attacks, the dosage of drugs is increased. Daily intake does not cause drug addiction.

Back to the table of contents

Elimination of provoking factors

It is very important to identify the allergen in the treatment of bronchial asthma. The cause of an attack is an allergic reaction of the body to a foreign agent. Medications, viral and bacterial diseases, household and food allergens can provoke an attack.

It is necessary to change pillows in the house, often carry out wet cleaning, avoid the use of chemical detergents. If funds permit, purchase an air humidifier in your home - it will reduce dust, purify the air and make breathing easier. You need to protect yourself not only from factors known to you, but also from potentially dangerous ones.

Eliminate the appearance of pets in the house, remove interior items that are dust collectors. Do not smoke in the house under any circumstances. During the flowering of plants in the spring and summer, start taking anti-allergic drugs in advance.

Physical activity can be started only with the permission of the doctor, if he considers that the course of the disease is well controlled.

Back to the table of contents

Respiratory gymnastics and diet therapy

Special exercises will help relieve the condition and avoid exacerbations. It is best to conduct classes outdoors or in well-ventilated areas.

The recommendation for patients with bronchial asthma is not to exercise if:

• there was an exacerbation recently;
• whether you feel or are sick.

Proper breathing will help not only as a preventive measure, but will also help calm down during attacks. It is necessary to alternate shallow breaths and forced exhalations.

Gymnastics will help strengthen the respiratory muscles and diaphragm, expand the lumen of the lungs. Strengthens the cardiovascular system and improves the patient's condition as a whole.

In the absence of a reaction to food, the diet should be complete and balanced. To regulate metabolic processes in the body, fractional nutrition is recommended. Strong broths should be eliminated and salt intake should be reduced.

Avoid foods containing dyes and preservatives - they can cause allergic reactions. Carefully study the composition of the products before purchasing, many artificial additives can provoke an exacerbation of the disease.

Remove strong-smelling spices from the diet, onions and garlic should be heat treated before use.

Back to the table of contents

Supervision by the attending physician

Even in the absence of exacerbations, you need to visit an allergist at least 3 times a year. The doctor will be responsible for the appropriateness of the prescribed treatment and monitoring the effectiveness of therapy. If the doctor advises you to increase the number of visits, follow his recommendations.

Visit your treating allergist if your seizures are more frequent or if you are unable to control seizures with available medications. Keep a diary, note all exacerbations in it, and against the background of which they arose. This will help the doctor navigate the nature of the course of the disease.

It is imperative to educate the asthma sufferer about the behavior patterns during attacks. Such work with children is especially important: you should contact a psychologist who will tell you how to behave correctly during an attack, not to be afraid of suffocation. It is also important to get into the habit of carrying an inhaler with you, even if there have been no attacks for a long time.

Inform your loved ones about your illness and what medications you need to give in an emergency. Inform your healthcare professional about drug intolerance in advance.

Behavior during an attack:

1. Stop contact with the agent who caused the seizure.
2. Take the prescribed immediate-acting bronchodilator medicine. Strictly follow the dosage recommended by your doctor.
3. Remain in peace, lie down for at least one hour. Make sure your breathing is normal.
4. If you cannot stop the attack on your own, urgently call the ambulance.

Often during suffocation, panic attacks occur, try to control emotions and bring all methods of help to automatism. Close people should also know where the drugs you need and the doctor's phone number are located in case of unforeseen situations.

You should urgently visit a doctor if:

• the number of attacks has increased;
• there were nocturnal exacerbations;
• the state of health has worsened;
• lips, nail plates turn blue, heartbeat increased;
• the prescribed drug does not produce the desired effect on suffocation.