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Review

Managing adult asthma: The 2019 GINA guidelines

Yael Mauer, MD, MPH and Rachel Metzger Taliercio, DO
Cleveland Clinic Journal of Medicine September 2020, 87 (9) 569-575; DOI: https://doi.org/10.3949/ccjm.87a.19136
Yael Mauer
Department of Internal Medicine and Geriatrics, Cleveland Clinic
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  • For correspondence: [email protected]
Rachel Metzger Taliercio
Departments of Pulmonary Medicine and Critical Care Medicine, Respiratory Institute, Cleveland Clinic; Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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    Figure 1

    Stepwise approach to asthma management.

    Based on Global Initiative for Asthma 2019 asthma management guidelines, reference 2.

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    TABLE 1

    Signs of airflow limitation variability

    Positive bronchodilator reversibility test
    Increase in forced expiratory volume in 1 second (FEV1) > 12% and > 200 mL from baseline 10–15 minutes after administering 200–400 μg albuterol or equivalent (more likely to be positive if bronchodilator is withheld before test: short-acting beta-agonists for at least 4 hours and long-acting beta-agonists for at least 15 hours before test)
    High variability in peak expiratory flow (highest of 3 readings), performed twice daily for 2 weeks
    Average daily diurnal variability > 10%
    Significant increase in lung function after 4 weeks of anti-inflammatory treatment
    Increase in FEV1 by > 12% and > 200 mL (or peak expiratory flow by > 20%) from baseline
    Positive exercise challenge test
    Fall in FEV1 of > 10% and > 200 mL from baseline
    Positive bronchial challenge test
    Fall in FEV1 from baseline of ≥ 20% with standard doses of methacholine or histamine, or ≥ 15% with standardized hyperventilation, hypertonic saline, or mannitol
    Excessive variation in lung function between visits
    Variation in FEV1 of > 12% and > 200 mL
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    TABLE 2

    Asthma, COPD, and overlap syndrome

    FeatureAsthmaCOPDAsthma-COPD overlap syndrome
    Age of onsetUsually childhoodUsually > 40Usually > 40, but may report symptoms in childhood or early adulthood
    SymptomsHigh variability over time, multiple triggers, worse at night or early morningContinuous, worse with exertion, chronic cough, and sputumPersistent exertional dyspnea but prominent variability
    BackgroundPersonal or family history of allergies or asthmaExposure to noxious substances like tobaccoPersonal or family history of allergies or asthma and personal noxious exposure
    Disease course and response to treatmentSymptoms improve spontaneously, respond to bronchodilator and inhaled corticosteroidSlowly progressive despite treatment, bronchodilator provides only limited reliefSymptoms are partly but significantly reduced by treatment
    Progression is typical and treatment needs are high
    Chest radiographyUsually normalHyperinflated lungsHyperinflated lungs
    SpirometryVariable and reversible airflow limitation, may be normal between symptoms or postbronchodilator
    Postbronchodilator increase in FEV1 > 12% and > 200 mL from baseline
    Increase of 400 mL from baseline is common
    Persistent airflow limitation
    FEV1 may be improved by therapy but postbronchodilator FEV1/FVC < 0.7 persists
    Postbronchodilator FEV1 ≥ 80% predicted indicates mild limitation and < 80% predicted indicates severe limitation
    Airflow limitation is persistent and not fully reversible, but often with current or historic variability
    FEV1 may be improved by therapy but postbronchodilator FEV1/FVC < 0.7 persists
    Postbronchodilator FEV1 ≥ 80% predicted indicates mild and < 80% indicates severe limitation
    • COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity

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Cleveland Clinic Journal of Medicine: 87 (9)
Cleveland Clinic Journal of Medicine
Vol. 87, Issue 9
1 Sep 2020
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Managing adult asthma: The 2019 GINA guidelines
Yael Mauer, Rachel Metzger Taliercio
Cleveland Clinic Journal of Medicine Sep 2020, 87 (9) 569-575; DOI: 10.3949/ccjm.87a.19136

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Managing adult asthma: The 2019 GINA guidelines
Yael Mauer, Rachel Metzger Taliercio
Cleveland Clinic Journal of Medicine Sep 2020, 87 (9) 569-575; DOI: 10.3949/ccjm.87a.19136
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Jump to section

  • Article
    • ABSTRACT
    • ASTHMA IS COMMON, ESPECIALLY IN CERTAIN GROUPS
    • PATHOPHYSIOLOGY AND CLINICAL MANIFESTATIONS
    • UPDATED MANAGEMENT GUIDELINES
    • CASE 1. A WOMAN WITH MILD ASTHMA
    • CASE 2. A MAN WITH MODERATE ASTHMA
    • CASE 3. AN ELDERLY WOMAN WITH SEVERE ASTHMA
    • ASTHMA-COPD OVERLAP SYNDROME
    • REFERENCES
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