Today we are launching a new Pulm PEEPs initiative! We are going to be reviewing some of the major guidelines that are available in pulmonary and critical care. We are starting by diving into the Global Initiative for Asthma (GINA) guidelines on asthma. The goal of this initiative is to breakdown the guidelines into digestible and helpful discussions, and to talk about key issues that are pointed out by the guideline authors. Our first episode will be the start of the GINA guidelines and we’re discussing the initial diagnosis and evaluation of patients with asthma.

Meet Our Co-Hosts

Rupali Sood grew up in Las Vegas, Nevada and made her way over to Baltimore for medical school at Johns Hopkins. She then completed her internal medicine residency training at Massachusetts General Hospital before returning back to Johns Hopkins, where she is currently a second year pulmonary and critical care medicine fellow alongside Tom. Rupali’s interests include interstitial lung disease, particularly as related to oncologic drugs. And she also loves bedside medical education.

Tom Di Vitantonio is originally from New Jersey and attended medical school at Rutgers, New Jersey Medical School in Newark. He then completed his internal medicine residency at Weill Cornell, where he also served as a chief resident. He currently is a second year pulmonary and critical care medicine fellow at Johns Hopkins, and he’s passionate about caring for critically ill patients, how we approach the management of pulmonary embolism, and also about medical education of trainees to help them be more confident and patient centered in the care they have going forward.

Key Learning Points

Understanding Asthma & the GINA Guidelines

Asthma is a heterogeneous disease characterized by recurring respiratory symptoms (breathlessness, wheezing, cough, chest tightness) with variable airflow limitation.
The 2023 & 2024 Global Initiative for Asthma (GINA) guidelines emphasize phenotyping asthma to improve diagnosis and treatment.
Asthma differs from other obstructive lung diseases due to reversible airway obstruction, which can be demonstrated through diagnostic testing.

Diagnosing Asthma

Clinical history is crucial, particularly identifying symptom triggers (cold air, exercise, allergens).
Spirometry is the standard diagnostic tool, looking for an increase in FEV1 or FVC ≥12% and 200 mL after bronchodilator use.
Alternative tests include:
- Peak expiratory flow monitoring over time.
- Bronchoprovocation tests (e.g., methacholine challenge) to assess airway hyperresponsiveness.
- Fractional exhaled nitric oxide (FENO) and blood eosinophils as markers of type 2 inflammation.

Asthma Phenotypes & Precision Medicine

Different asthma phenotypes guide personalized treatment approaches:
- Type 2 inflammation: Characterized by eosinophilic inflammation, high FeNO, good steroid responsiveness, and potential for biologic therapy.
- Non-Type 2 inflammation: Associated with neutrophilic inflammation, poor steroid responsiveness, and potential benefit from macrolides or bronchodilators.
Asthma-COPD overlap requires a distinct treatment approach due to persistent obstruction.

Imaging & Adjunctive Tests

Imaging is not routinely needed in asthma but can be useful for:
- Bronchiectasis (suspected allergic bronchopulmonary aspergillosis – ABPA).
- Asthma-COPD overlap (CT chest for emphysema).
- Chronic sinusitis or nasal polyps (CT sinus imaging).

Assessing Asthma Control

Asthma is not a one-time diagnosis; continuous reassessment is crucial.
Asthma control is assessed at every visit, considering:
- Symptom frequency
- Exacerbations
- Inhaler technique
- Comorbidities
Rule of Twos: Asthma is not well-controlled if:
- Symptoms occur >2 times per week.
- Nighttime awakenings >2 times per month.
- Rescue inhaler use >2 times per week (excluding pre-exercise use).
Peak flow meters are valuable for self-monitoring and guiding asthma action plans.

Conclusion

Asthma assessment is a continuous process, incorporating history, spirometry, biomarkers, and patient-reported symptoms.
Future episodes will cover asthma treatment, including biologics and inhaler therapy.
Infographics and questions will accompany this series for further learning.

Infographic

Board Style Questions

References

Mauer Y, Taliercio RM. Managing adult asthma: The 2019 GINA guidelines. Cleve Clin J Med. 2020 Aug 31;87(9):569-575. doi: 10.3949/ccjm.87a.19136. PMID: 32868307.

Matera MG, Rinaldi B, Annibale R, De Novellis V, Cazzola M. The pharmacological management of asthma in adults: 2023 update. Expert Opin Pharmacother. 2024 Mar;25(4):383-393. doi: 10.1080/14656566.2024.2332627. Epub 2024 Mar 20. PMID: 38497368.

Arismendi E, Ribo P, García A, Torrego A, Bobolea I, Casas-Saucedo R, Palomino R, Picado C, Muñoz-Cano R, Valero A. Asthma Control According to GINA 2023: Does Changing the Criteria Improve Asthma Control? J Clin Med. 2024 Nov 6;13(22):6646. doi: 10.3390/jcm13226646. PMID: 39597790; PMCID: PMC11594371.

http://ginasthma.org/2023-gina-main-report/

2024 GINA Main Report

93. Guidelines Series: GINA Guidelines – Asthma Diagnosis and Assessment

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