Managing adult asthma: The 2019 GINA guidelines

Yael Mauer; Rachel Metzger Taliercio

doi:10.3949/ccjm.87a.19136

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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

Feature	Asthma	COPD	Asthma-COPD overlap syndrome
Age of onset	Usually childhood	Usually > 40	Usually > 40, but may report symptoms in childhood or early adulthood
Symptoms	High variability over time, multiple triggers, worse at night or early morning	Continuous, worse with exertion, chronic cough, and sputum	Persistent exertional dyspnea but prominent variability
Background	Personal or family history of allergies or asthma	Exposure to noxious substances like tobacco	Personal or family history of allergies or asthma and personal noxious exposure
Disease course and response to treatment	Symptoms improve spontaneously, respond to bronchodilator and inhaled corticosteroid	Slowly progressive despite treatment, bronchodilator provides only limited relief	Symptoms are partly but significantly reduced by treatment Progression is typical and treatment needs are high
Chest radiography	Usually normal	Hyperinflated lungs	Hyperinflated lungs
Spirometry	Variable 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