Gina on bronchial asthma. The role of the GINA structure in the treatment and control of bronchial asthma Definition of bronchial asthma by gin

GINA is an international structure designed to solve the problem of combating bronchial asthma on a global scale. BA is a heterogeneous disease with localization of the inflammatory process in the respiratory tract, which is chronic in nature. It is a worldwide problem - people of all ages and social groups are susceptible to it. The disease requires constant monitoring due to its incurability.

What is the gina asthma program?

In 1993, a task force was created to study the worldwide problem of bronchial asthma under the leadership of the World Health Organization and the US Heart, Lung and Blood Institute. The team's activities led to the appearance of a report on the possibilities of treatment and prevention of bronchial asthma.

As a result, the GINA organization arose, which is a structure of interacting doctors, medical institutions and authorities. Later, this structure grew into the Assembly, bringing together experts in this field from around the world.

The purpose of the association’s work was to develop rules for the treatment of people suffering from asthma and to inform the population.

The organization deals with the implementation of scientific research results in the standards of asthma treatment and their improvement. There is still a low cure rate for asthma worldwide. The organization makes every effort to ensure the availability of medicines, methods for implementing effective programs, and recording results. The latest GINA report is not just a description, but a strategy based on a strong new evidence base about how best to implement clinical guidelines for the management of asthma.

Definition of asthma according to GINA 2016

By 2012, information appeared that bronchial asthma is a heterogeneous disease. The Gin Association has come up with a precise definition of this disease: asthma is chronic and causes inflammation of the airways.

Early diagnosis and effective treatment of the disease is necessary, as it reduces a person’s ability to work, thereby indirectly affecting the economy. According to the GINA 2016 description, bronchial asthma is defined by the following criteria:

These signs appear as a result of the reaction of the respiratory tract to irritants. They narrow and actively produce large amounts of mucus. These factors prevent the free passage of air into the lungs.

Inflamed bronchi become sensitive to allergens. Therefore, the disease has two types: allergic, accompanied by a runny nose and urticaria, as well as a non-allergic form of bronchial asthma.

People of any age and social status are affected by the disease. It most often occurs in children, who in most cases can get rid of it as they grow older. But the number of people suffering from bronchial asthma is growing steadily, crossing the border of three hundred million people.

Classification of asthma according to GINA

According to the classification created by GINA 2016, bronchial asthma is divided into phenotypes. They vary depending on the clinical manifestations and age of the patient. There are five types of asthma:

Diagnosis of asthma at the initial stage, together with adequate therapy, can reduce the socio-economic damage caused by the disease, as well as significantly improve the lives of patients.

There are five stages of controllable signs and ways to reduce the risk of developing asthma in the future:

We can conclude that ICS, as well as their combination with LABA, is becoming the basis for the treatment of bronchial asthma. This helps relieve inflammation in a short time. The severity of the disease is measured only by the degree of treatment applied. The success of therapy should be assessed every three to six months. The intensity of treatment is reduced if a positive result is observed. If there is no effect, treatment is applied at the next stage.

A treatment plan has been developed in stages. According to this development, several recommendations must be followed:

• it is necessary to teach the patient self-help during the active manifestation of symptoms of bronchial asthma;
• treatment for concomitant diseases such as obesity and smoking should be carried out;
• You need to pay attention to non-drug treatment: eliminating sensitizers, reducing body weight, and physical activity.

GINA (Global Initiative For Asthma) is an international organization whose goal is to combat bronchial asthma throughout the world. Asthma is a chronic irreversible disease; under unfavorable conditions it progresses and threatens a person’s life. The main task of the structure is to create conditions under which complete control over the disease becomes possible. Bronchial asthma is diagnosed in people, regardless of age, gender, or social status. Therefore, the problems that the GINA structure solves always remain relevant.

History of the organization

Despite scientific advances in the field of practical medicine and pharmaceuticals, the prevalence of bronchial asthma has increased every year. This trend was especially observed in children. The disease inevitably leads to loss of ability to work. And expensive treatment does not always give positive results. Differences in the organization of healthcare in each individual country and limited availability of medicines did not make it possible to bring world statistics on the disease closer to real indicators. This made it difficult to determine methods of productive treatment and quality control of the disease.

To solve this problem, in 1993. A special working group was organized on the basis of the American Institute studying the pathology of the heart, lungs and blood, with the support of WHO. Its goal is to develop a plan and strategy for the treatment of bronchial asthma, reduce cases of disability and early death, and allow patients to remain able to work and vitally active.

A special program “Global strategy for the treatment and prevention of bronchial asthma” has been developed. In 2001, GINA initiated World Asthma Day to attract public attention to the current problem.

To achieve control over bronchial asthma, Gina gives recommendations regarding diagnosis, treatment, and prevention of disease progression. The program involves international experts, medical specialists, and the world's largest pharmaceutical companies.

One of the goals of the structure is to develop a strategy for early diagnosis and effective treatment with minimal financial costs. Since asthma therapy is an expensive undertaking, it is not always effective. Through new programs, the organization indirectly impacts the economy of each geographic region.

Definition and interpretation of asthma according to GINA 2016

Based on the results of numerous studies, bronchial asthma was defined as a heterogeneous disease. This means that one symptom or sign of pathology is caused by mutations in different genes or numerous changes in one.

In 2016, Gina gave the exact formulation of the disease: bronchial asthma is a chronic disease that causes inflammation of the mucous membrane of the respiratory tract, in which many cells and their elements are involved in the pathological process. The chronic course contributes to the development of bronchial hyperreactivity, which occurs with episodic exacerbations.

Clinical signs:

• wheezing - indicates that respiratory sounds are formed in the bronchi with the smallest lumen diameter and bronchioles;
• expiratory shortness of breath - exhalation is significantly difficult due to accumulated thick sputum, spasm and swelling;
• feeling of congestion in the chest;
• cough at night and early in the morning; it is dry, persistent, and severe in nature;
• compression in the chest, suffocation – accompanied by attacks of panic;
• increased sweating.

Episodes of exacerbations are associated with the dynamics of severe obstruction of the bronchi and lungs. Under the influence of medications, it is reversible, sometimes spontaneous, without objective reasons.

There is a close relationship between atopy (hereditary predisposition to the production of specific allergic antibodies) and the development of bronchial asthma. Also important is the predisposition of the bronchial tree to narrow the lumen in response to the action of a provoking agent, which normally should not cause any reactions.

With adequate treatment, bronchial asthma can be controlled. Therapy helps manage the following symptoms:

• disturbance in the duration and quality of sleep;
• functional failures of the pulmonary system;
• restriction of physical activity.

With the correct selection of emergency medications, resumption of exacerbations is extremely rare, for random reasons.

Factors on which the development and clinical manifestations of asthma depend

According to GINA research, bronchial asthma develops when exposed to provoking or conditioning factors. Often these mechanisms are interconnected. They are internal and external.

Internal factors:

• Genetic. Heredity is involved in the development of bronchial asthma. Scientists are searching for and studying genes in different classes of antibodies, studying how this can affect respiratory function.
• Gender of a person. Among children under 14 years of age, boys are at risk. The frequency of the disease is twice as high as among girls. In adulthood, the situation develops the other way around; women are more likely to get sick. This fact is correlated with anatomical features. Boys have smaller lungs than girls, and women have larger lungs than men.
• Obesity. Overweight people are more susceptible to developing asthma. However, the disease is difficult to control. In obese people, the process of lung pathology is complicated by concomitant diseases.

External factors:

• Allergens. Agents that can presumably provoke AD include cat and dog dander, house dust mites, fungus, and cockroaches.
• Infections. The disease in childhood can develop under the influence of viruses: RSV, parainfluenza. But at the same time, if a child encounters these pathogens in early childhood, he develops immunity and reduces the risk of asthma in the future.
• Professional sensitizers. These are allergens that a person comes into contact with at the workplace - substances of chemical, biological and animal origin. An occupational factor is recorded in every 10 patients with asthma.
• The effect of nicotine during smoking. The toxic substance contributes to the progression of deterioration in lung function, makes them resistant to inhalation treatment, and reduces control over the disease.
• Polluted atmosphere and microclimate in living quarters. Such conditions reduce the function of the respiratory system. A direct relationship with the development of asthma has not been established, but it has been confirmed that dusty air causes exacerbations.
• Nutrition. The risk group includes infants on artificial nutrition, as well as people who subject all products to thorough heat treatment before consumption, excluding the possibility of consuming large quantities of raw vegetables and fruits.

What criteria are used to classify asthma?

Classification of bronchial asthma according to GINA 2015-2016. was formed according to various criteria.

Etiology. Scientists are constantly trying to classify the disease according to etiological data. But this theory is ineffective, since in many cases it is not possible to accurately determine the true cause of bronchial asthma. Nevertheless, medical history plays an important role in the initial diagnosis of the disease.

Phenotype. Every year, information about the role of genetic changes in the body increases and is confirmed.. When assessing the patient’s condition, they take into account a set of signs that are characteristic of each individual patient and depend on the direct influence of the environment. Using a multivariate statistical procedure, data on possible phenotypes is collected:

• eosinophilic;
• noneosinophilic;
• aspirin asthma;
• tendency to exacerbation.

Classification according to feasibility of asthma control. This takes into account not only control over clinical manifestations, but also over possible risks in the future.

Characteristics by which the condition is assessed:

• signs of pathology that occur during the day;
• restrictions on physical activity;
• need for emergency medications;
• assessment of lung function.

Depending on the indicators, the disease is classified as follows:

• controlled asthma;
• frequently controlled asthma;
• uncontrolled asthma.

According to GINA, all data about the patient is first collected, and then the treatment that will give the best results is selected. The organization's strategy provides for the availability of therapy for patients.

Bronchial asthma (BA) is considered a dangerous disease that is a problem throughout the world. Diagnosis in the early stages of asthma and proper treatment significantly reduce the socioeconomic harm from bronchial asthma and alleviate the manifestation of symptoms in patients.

The most serious complication of asthma is status asthmaticus.

GINA (Global Initiative on Asthma) was developed to determine the classification of bronchial asthma, as well as to develop a treatment plan and preventive actions.

According to the new concept, asthma is a heterogeneous disease in which a chronic inflammatory process is localized in the respiratory tract.

Diagnosis is carried out based on symptoms such as whistling breathing, shortness of breath, coughing, and tightness in the chest area. Symptoms are variable in duration and intensity and are associated with chronic respiratory obstruction.

Classification of bronchial asthma GINA 2014

1. Cause of occurrence (endogenous, atopic, aspirin, occupational, mixed);
2. Level of control (controlled, partially controlled, uncontrolled);
3. Exacerbation (mild, moderate and severe).

Depending on age and clinical manifestations, asthma phenotypes are distinguished:

Timely and accurate diagnosis plays an important role in the treatment of patients with asthma. To confirm the diagnosis of bronchial asthma, two important parameters are taken into account:

1. The presence of respiratory symptoms, which vary in intensity and duration: difficulty breathing, wheezing, coughing, stiffness in the chest area;

2. Evidence of variable obstruction in the bronchi.

Clinical picture of the patient (risk factor)

It is necessary to identify the severity of asthma for correct therapy. Based on the GINA 2014 concept, to assess the severity of bronchial asthma, it is recommended to use retrospective examination control (based on the volume of treatment in order to achieve asthma control after a couple of months of well-chosen primary treatment).

There are three degrees of severity of bronchial asthma.

• mild degree (diagnosed when asthma can be controlled with short-acting beta-agonists (SABAs), only when necessary, or small doses of ICS, as well as with the use of anti-leukotriene drugs ALP);
• degree of moderate severity (established with good control of BA, when treatment includes small doses together with long-acting beta-agonists, or ICS in medium doses;
• severe severity of asthma (to control the symptoms of asthma, you need to use drugs in combination and in large doses, for example, ICS in large doses with beta-agonists, in some cases it is not possible to control asthma).

It is also very important to recognize the difference between severe asthma and poorly controlled asthma.

Before diagnosing severe asthma, it is necessary to ensure that all possible causes of lack of control are excluded:

1. Incorrect diagnosis of asthma;
2. Inappropriate inhalation technique;
3. Reduced susceptibility to treatment;
4. Presence of concomitant diseases (obesity, rhinosinusitis, etc.)

Basic therapy for asthma

An important aspect is the appointment of the correct amount of treatment in patients who have never previously undergone asthma therapy, or in patients newly diagnosed with asthma. According to GINA recommendations, initial therapy directly depends on clinical signs, as well as the presence of provoking factors.

There are 5 steps to control symptoms and reduce future risks of asthma:

1. First step: short-acting β-agonist drugs, relieve the manifestations of asthma, used if necessary in patients with rare manifestations of symptoms;
2. Second stage: drugs with low doses for long-term control are combined with drugs that relieve the manifestations of asthma, only if necessary;
3. Third stage: a drug that stops attacks, as well as one or more for control;
4. Fourth stage: two or more drugs to control asthma are supplemented with a drug that stops attacks, used if necessary;
5. Fifth stage: additional therapy.

The updated GINA concept is aimed at improving monitoring of patients with bronchial asthma, as well as achieving positive treatment results.

The strategy is aimed at implementation in a variety of health systems, which is characterized by access to treatment.

S.E. Tsyplenkova, Ph.D., pulmonologist, Separate structural unit of the Research Clinical Institute of Pediatrics, State Educational Institution of Higher Professional Education, Russian National Research Medical University named after. N.I. Pirogov Ministry of Health of the Russian Federation, Moscow

Bronchial asthma (BA) remains a serious worldwide problem. Everywhere, people of all ages suffer from this chronic respiratory disease, which, if not treated effectively, significantly limits the daily life of patients and even leads to death. The prevalence of asthma, especially among children, is steadily increasing, which is associated both with the deterioration of the environmental situation and with more advanced diagnostics. AD causes significant harm, associated not only with treatment costs, but also with loss of ability to work and limitation of social activities.
Keywords: bronchial asthma, Global strategy for the treatment and prevention of bronchial asthma, levels of control, principles of self-control, syndrome of combination of bronchial asthma and chronic obstructive pulmonary disease (COPD).
Key words: bronchial asthma, Global Initiative for Asthma (GINA), control levels, the principles of self-control, syndrome the combination of bronchial asthma and chronic obstructive pulmonary disease (ACOS).

Over the past decades, ideas about asthma have changed radically, and new opportunities have emerged for its timely diagnosis and effective treatment. However, the diversity of healthcare systems in different countries and differences in the availability of drugs for the treatment of asthma have created a need to adapt the most effective and cost-effective recommendations for the treatment of asthma to local conditions around the world. In this regard, in 1993, the National Heart, Lung and Blood Institute (NIHLB, USA), together with the World Health Organization (WHO, WHO), created a working group, the result of which was the report “Global Strategy for the Treatment and Prevention of Bronchial Asthma” (Global Initiative for Asthma, GINA (English)) to ensure the implementation of the results of modern scientific research into the standards of asthma treatment. However, despite all efforts to disseminate the GINA recommendations, which have been updated many times since then, and the availability of effective drugs, data from international studies indicate a low level of asthma control in many countries. In this regard, a new edition of GINA appeared in 2014. The following overview of this document focuses on the main positions that have undergone fundamental changes since the previous edition of GINA.

It should be noted that GINA-2014, unlike previous versions, is a reference book for real clinical practice, based on the principles of evidence-based medicine, standardized results of treatment and prevention of asthma, intended for countries with different levels of development.

What is known today about bronchial asthma? First of all, AD is a chronic disease that can be controlled, but cannot be cured. Asthma is a heterogeneous disease characterized by chronic inflammation of the airways. The characteristic symptoms of asthma - wheezing, shortness of breath, difficulty breathing, a feeling of congestion in the chest, cough, varying in time of appearance, frequency and intensity - are associated with a variable limitation of the expiratory (exhaled) air flow. Symptoms of bronchial obstruction, caused in asthma by bronchospasm, thickening of the airway wall and an increase in the amount of mucus in the lumen, may appear or intensify in response to viral infections, allergens, smoking, physical activity and stress.

When initially identifying symptoms typical of BA, according to expert recommendations, it is necessary to conduct a detailed history taking, clinical examination, spirometry (or peak flowmetry) with a test to detect bronchial reversibility; When the diagnosis of asthma is confirmed, appropriate treatment is indicated. During the examination, an alternative diagnosis can be verified and a trial treatment for the suspected disease can be prescribed. In case of an atypical picture of BA, a thorough further examination is carried out; if it is impossible to confirm the diagnosis of BA and exclude alternative diagnoses, empirical therapy with inhaled glucocorticosteroids (ICS) and short-acting beta-2 agonists (SABA) is proposed as needed, assessing the effect after 1-2 months.

During the treatment of asthma, it is recommended to regularly conduct a dynamic assessment of the effectiveness of asthma therapy, which consists of indicators of symptom control over the last 4 weeks and identification of risk factors for an unfavorable prognosis of asthma, which include, among others, low respiratory function indicators. Monitoring asthma treatment also includes checking inhalation technique and adherence to treatment, identifying side effects of drugs, and drawing up a written action plan for the patient after clarifying the patient's preferences and goals in asthma treatment.

The presence of daytime asthma symptoms more than 2 times a week, nighttime symptoms (waking up due to asthma); the need for drugs that relieve asthma attacks more than 2 times a week and the limitation of activity due to asthma together determine the level of asthma control: in the absence of symptoms, controlled asthma is diagnosed; partially controlled asthma requires the presence of 1-2 signs, uncontrolled asthma - 3-4 signs. It should be noted that in GINA-2014, respiratory function indicators are excluded from assessing the level of asthma control; they are recommended to be used when assessing risk factors for an unfavorable prognosis.

It is necessary to take into account that such concomitant diseases as chronic rhinosinusitis, gastroesophageal reflux disease (GERD), obesity, obstructive sleep apnea syndrome, depression, anxiety disorders always contribute to the symptoms of asthma and lead to a decrease in quality of life, which requires appropriate adjustments in the plan treatment of such patients.

The severity of asthma in GINA-2014 is recommended to be assessed retrospectively (usually after several months of basic treatment) based on the amount of therapy necessary to control the symptoms of asthma and its exacerbations. It is especially emphasized that the severity of asthma is not constant: it can change over time, including under the influence of new methods of therapy.

Thus, in mild asthma for patients with rare symptoms (less than 2 times a month) without concomitant risk factors for exacerbations, short-acting beta-2 agonists (SABAs) are recommended at the first stage of therapy to relieve asthma symptoms, but so far little data on safety have been accumulated SABA monotherapy. For patients with mild asthma and a high risk of exacerbations, regular use of low-dose ICS with SABA on demand (second-step therapy) is recommended, as low-dose ICS for mild asthma has been shown to reduce symptoms and reduce the risk of exacerbations, hospitalizations and deaths. As an alternative, especially in patients with concomitant allergic rhinitis or who refuse ICS treatment, leukotriene receptor antagonists (LAR) or low-dose theophyllines with on-demand SABAs can be used for mild asthma. However, in clinical studies, the effectiveness of ALTR and theophyllines was significantly lower than that of treatment with low doses of ICS. In case of seasonal exacerbations of asthma and the absence of symptoms in the off-season, intermittent courses of ICS and SABA are recommended as needed, and it is proposed to start taking ICS immediately when the first symptoms appear and continue treatment for another 4 weeks after the end of the flowering season. Please note that at each stage, before making a decision to increase the volume of therapy, it is necessary to check the inhalation technique and adherence to treatment.

At the third stage of therapy, it is recommended to take low doses of ICS in combination with LABAs and SABAs as needed (or low doses of budesonide/beclomethasone + formoterol as needed). It has been proven that such therapy helps reduce symptoms and improve pulmonary function, but does not significantly affect the frequency of exacerbations and is quite expensive. At the same time, LABAs reduce symptoms, reduce the risk of exacerbations, increase FEV1 and allow the dose of ICS to be reduced. A less effective alternative is to increase the dose of ICS (to medium or high doses) or add ALTR (or theophyllines) to low doses of ICS.

At the fourth stage of therapy, a combination of medium or high doses of ICS and LABA and SABA is used as needed (or low doses of ICS/formoterol as needed); an alternative is to prescribe high-dose ICS in combination with ALTR or low-dose theophyllines (and SABA or low-dose ICS/formoterol as needed).

At the fifth stage of therapy, if maximum volumes of inhaled anti-inflammatory therapy are insufficiently effective, the addition of the anti-IgE drug omalizumab (Xolair) (and SABA or low doses of ICS/formoterol as needed) is recommended. An alternative is to prescribe low doses of systemic steroids (less than 7.5 mg/s for prednisolone), which generally helps reduce the risk of exacerbations and in some cases allows you to reduce the dose of ICS, but at the same time significantly increases the risk of systemic adverse events and requires careful monitoring.

An important problem remains insufficient control over asthma symptoms during therapy. To improve it, it is proposed to regularly evaluate inhalation technique and patient adherence to treatment. In doubtful cases, a thorough re-examination is necessary to confirm the diagnosis of asthma; in case of normal pulmonary function and the presence of typical complaints, it is recommended to reduce the daily dose of ICS by half for 2-3 weeks, followed by an assessment of symptoms and parameters of external respiration. It is very important to eliminate all risk factors (smoking, taking beta blockers, non-steroidal anti-inflammatory drugs, exposure to allergens), evaluate and select therapy for concomitant diseases (rhinitis, obesity, GERD, anxiety, depression, etc.). If symptoms of unstable asthma persist, after a thorough assessment of the risk-benefit ratio, transfer to the next stage of therapy is recommended.

The long-term goals of asthma treatment in GINA-2014 include achieving a good level of symptom control and a normal level of physical activity, minimizing the risk of exacerbations, the formation of fixed obstruction and adverse events of drug therapy. Achieving these goals requires partnerships between patients and healthcare professionals at different levels. The choice between drugs for basic therapy of asthma is recommended to be made in accordance with national guidelines and recommendations based on data on effectiveness in clinical trials and real practice, safety of use, availability and cost. When choosing therapy to control asthma symptoms and reduce the risk of poor prognosis, it is also necessary to take into account the individual characteristics of patients and their preferences. Risk factors or predictors of insufficient response to therapy should be taken into account (smoking, history of severe exacerbations, concomitant diseases, etc.), practical skills in inhalation technique, adherence to treatment, affordability of drugs.

The main principle of initial therapy for asthma is early initiation of treatment immediately after diagnosis. Low doses of ICS are recommended if daytime asthma symptoms occur more than 2 times a month (nighttime symptoms more than once a month) and are combined with risk factors for exacerbations. Starting with a higher level of asthma therapy is indicated if the frequency of daytime symptoms is higher (or nighttime symptoms occur more than once a week), especially if there are risk factors for exacerbations. At the onset of asthma with a severe exacerbation, it is permissible, after a short course of systemic steroids, to begin basic therapy with high doses of ICS (Table 1) or ICS/LABA, followed by a gradual reduction in the volume of basic treatment as the condition stabilizes.

Table 1.

Daily doses of inhaled glucocorticosteroids (with comparable effectiveness) for patients with asthma

ICS - inhaled corticosteroids, CFC - chlorofluorocarbon, propellant gas in a metered-dose aerosol inhaler, HFA - hydrofluoroalkane, propellant gas in a metered-dose aerosol inhaler, DPI - metered-dose powder inhaler

It has been established that the greatest clinical benefits of ICS are observed when using low doses; The effectiveness of high-dose ICS in asthma is debated; most cases are associated with an increased risk of systemic adverse events.

It is recommended to evaluate the effectiveness of treatment for BA 1-3 months after the start of treatment (after an exacerbation of BA - a week later), and subsequently - after 3-12 months (in pregnant patients with BA - every 4-6 weeks). After 2-3 months, if the level of asthma control is insufficient, after assessing the inhalation technique and real adherence to treatment, it is recommended to increase the volume of basic therapy (“step up”).

When a viral infection occurs or seasonal exposure to allergens, if there is a written action plan, a patient with asthma can independently increase the volume of basic therapy for 1-2 weeks (this is especially true for patients receiving low doses of ICS/formoterol in the basic therapy regimen and for the relief of attacks). A reduction in the volume of therapy (“step down”) is recommended after achieving good control of asthma after 3 months to the minimum effective dose of ICS, which completely controls the symptoms of asthma and prevents its exacerbations.

GINA-2014 recommends self-management tactics for incipient exacerbations of asthma, which implies constant monitoring of symptoms and/or pulmonary function (PEF, FEV1), the presence of an individual action plan, and regular contact between the patient and a specialist to discuss treatment issues. If an exacerbation develops, patients are recommended to increase the frequency of use of the rescue inhaler and the volume of basic therapy with an assessment of the condition after 48 hours: if PEF or FEV1 remains less than 60% of the best value and there is no improvement, it is recommended to continue using the rescue inhaler, basic therapy in combination with administration of prednisolone (40-50 mg/s) and mandatory contact with a doctor. It is emphasized that severe exacerbations of asthma can be sudden and without obvious causes, even in mild and well-controlled asthma.

Although most patients can achieve treatment goals and have well-controlled asthma, some patients do not achieve control despite optimal therapy. The term “difficult to treat” asthma implies the presence of various concomitant diseases, continued contact with allergens, low adherence to treatment, and inadequate inhalation technique. In resistant (treatment-resistant, refractory) severe asthma, symptoms or exacerbations are poorly controlled, despite the highest level of recommended treatment. This requires more careful identification of the causes of poor asthma control and careful monitoring of the condition of such patients.

GINA 2014 described for the first time the syndrome of combination of asthma with chronic obstructive pulmonary disease (COPD) (ACOS), which is characterized by persistent airflow limitation with individual manifestations usually associated with both asthma and COPD. The relevance of this problem is due to the fact that the prognosis of patients with signs of asthma in combination with COPD is worse than with only one diagnosis: they are characterized by more frequent and severe exacerbations, lower quality of life, rapid regression of pulmonary function, high cost of treatment and mortality . According to the literature, the prevalence of the syndrome of combination of BA and COPD among patients with chronic respiratory diseases varies from 15 to 55% and strongly depends on age and gender. It is believed that if a patient has more than three signs characteristic of asthma and COPD or has an equal number of signs of both diseases (Table 2), then this is obvious evidence of a combination syndrome of asthma and COPD.

Table 2.

Characteristic symptoms of asthma and COPD

Initial therapy for asthma and COPD combined syndrome (ACOS) is based on syndromic assessment and spirometry: if the patient has dominant manifestations of asthma, then treat as asthma; if manifestations of COPD dominate, then treat as COPD. If syndromic assessment confirms the presence of ACOS or doubts remain about the diagnosis of COPD, then treatment for asthma should be initiated while additional investigations are performed. Before starting treatment, it is necessary to carefully weigh the effectiveness and safety of therapy: for any manifestations of BA, it is recommended to avoid prescribing a LABA without ICS; for any manifestations of COPD, symptomatic treatment with bronchodilators or combination therapy (ICS/LABA) is indicated, avoiding the prescription of ICS monotherapy. In case of a confirmed diagnosis of ACOS, ICS therapy is indicated in combination with LABAs and/or long-acting anticholinergics (LAAs). Important strategic directions in the treatment of ACOS and COPD remain motivated smoking cessation, various methods of pulmonary rehabilitation, vaccination against pneumococcal infection and influenza, and treatment of concomitant diseases.

Diagnosis of asthma in children, according to the GINA-2014 recommendations, is mainly based on characteristic symptoms (wheezing, coughing, difficulty breathing, waking up at night and/or limitation of physical activity due to these symptoms) in combination with a family history and the results of a clinical examination .

Asthma in children under 5 years of age is characterized by a recurring or persistent cough, worsening at night and accompanied by wheezing and difficulty breathing. It is typical that a cough in asthma can be provoked by physical activity, crying, screaming, or tobacco smoke in the absence of signs of a respiratory infection. Asthma in children is also characterized by repeated episodes of wheezing, including during sleep or when exposed to various triggers (viral infections, physical activity, laughter, crying, or under the influence of tobacco smoke and various pollutants). The same factors in asthma in children provoke the appearance of difficult or heavy breathing with prolonged exhalation; it is usually accompanied by a decrease in physical activity (shortness of breath when running, crying, laughing, playing) and rapid fatigue. Of course, the likelihood of a diagnosis of asthma in children increases significantly when a family history of asthma is identified (especially if parents and siblings have asthma), as well as in the presence of other allergic diseases in the child (atopic dermatitis, allergic rhinitis, etc.).

When prescribing basic therapy for asthma in young children, low doses of ICS and short-acting bronchodilators on demand (SABA) are preferred. The diagnosis of asthma in a child can be confirmed when persistent improvement is achieved during a 2-3-month trial treatment with low doses of inhaled corticosteroids and the resumption of asthma symptoms after discontinuation of therapy.

An important issue remains predicting the risk of asthma exacerbations in the near future. These signs include the persistence of uncontrolled asthma symptoms, more than one severe exacerbation in the previous year, the onset of pollination season, continued exposure to tobacco smoke and various pollutants, unresolved contact with allergens, especially when viral infections are associated, unfavorable social and psychological background in the family, low treatment adherence and poor inhalation technique. Factors in the formation of fixed bronchial obstruction in asthma in children include severe asthma with hospitalization in the ICU and a history of bronchiolitis. In addition, possible side effects of the therapy should be taken into account (systemic - with repeated courses of systemic steroids or the use of high doses of ICS; local - due to improper inhalation technique, including various damage to the skin of the face and eyes with prolonged use of a nebulizer mask or spacer).

GINA-2014 also proposed using a stepwise approach to therapy for children with asthma under 5 years of age, which involves 4 stages of treatment. The first stage of therapy is used in children with rare asthma symptoms and a low risk of exacerbations and involves the use of SABA as needed in the absence of basic therapy. The second stage of treatment, involving the use of ICS in low doses (beclomethasone dipropionate (HFA) - 100 mcg/s, budesonide pMDI + spacer - 200 mcg/s, budesonide (suspension for nebulizer) - 500 mcg/s, fluticasone propionate (HFA) - 100 mcg/s, ciclesonide - 160 mcg/s), intended for children with more frequent asthma symptoms or with rare symptoms and a high risk of exacerbations; Antileukotrienes (ALTRs) have been proposed as an alternative. At the third stage of therapy, for severe asthma symptoms that are not controlled by taking low doses of ICS, it is recommended to use a double daily dose of ICS (as an alternative, the previous dose of ICS + ALTR). At the fourth stage of treatment for severe asthma in a child under 5 years of age, the use of a double daily dose of ICS in combination with ALTR is indicated.

For children aged 0-3 years, the preferred method of delivering drugs for the basic treatment of asthma is a pMDI in combination with a spacer equipped with a face mask; An alternative is nebulizer therapy with a face mask. For patients with asthma aged 4-5 years, it is preferable to use a MDI in combination with a spacer with a mouthpiece for basic therapy, but it is also possible to use a spacer with a face mask or a nebulizer with a mouthpiece or face mask.

Early symptoms of an incipient exacerbation of asthma in children under 5 years of age should be considered the sudden or gradual appearance/intensification of wheezing and difficulty breathing, the appearance/intensification of cough, especially out of sleep, drowsiness or lethargy, weakness, decreased motor activity, changes in behavior, including difficulties with feeding , insufficient response to taking “relieving” drugs; Often the symptoms of viral infections can mask the incipient exacerbation of asthma.

At any stage of treatment, if the activity of a child with asthma suddenly changes, and the symptoms of asthma are not relieved by taking inhaled bronchodilators or their period of action is progressively shortened, then it is necessary to repeat SABA inhalations every few hours and monitor the response; in the absence of a pronounced effect, parents should begin therapy for exacerbation of asthma at home. Initial treatment should begin with 2 doses (200 mcg of salbutamol or its equivalent) through a spacer (with or without a mask, depending on age), if there is no effect, two similar inhalations are acceptable at intervals of 20 minutes; after this, the child should be under close medical supervision (if necessary, up to several days). If symptoms persist after taking 6 doses of SABA over 2 hours or there is no significant improvement within 24 hours, then high-dose ICS or systemic steroids are prescribed (however, it is indicated that both types of treatment can be accompanied by pronounced systemic effects and require careful medical supervision).

Indications for emergency hospitalization of children with asthma under 5 years of age, according to the GINA-2014 recommendations, are episodes of irregular breathing and/or respiratory arrest, speech and swallowing disorders, diffuse cyanosis, retraction of intercostal spaces, a drop in saturation when breathing room air below 92%, sudden weakening of breathing on auscultation, lack of response to initial SABA therapy, poor response to successive inhalations of 6 doses of salbutamol (2 doses three times at 20-minute intervals), persistent shortness of breath after using SABA (even if some improvement in the child’s condition was noted), inability to organize treatment exacerbations at home.

In GINA-2014, much attention is paid to methods of non-drug prevention and rehabilitation of patients with asthma, which, of course, helps to increase the effectiveness of the measures taken and improve the quality of life of these patients.

In general, it should be noted that GINA-2014 is a recommendation document that incorporates global experience in combating such a socially significant disease as bronchial asthma. I would like to hope that modern Russian consensus documents on the treatment and prevention of asthma will reflect the main provisions of GINA-2014, taking into account the organizational and economic capabilities of our healthcare system, which will make the lives of patients with asthma better and safer.

The treatment of bronchial asthma is based on a stepwise approach. For this purpose, five steps have been developed, where treatment strategies are determined depending on the clinical course, the presence of exacerbations or the possibility of their development, and the degree of control over the disease. The advantage of this approach is that it makes it possible to achieve a high degree of control over bronchial asthma using minimal medications.

Principles of stepwise treatment of bronchial asthma

Bronchial asthma is a chronic inflammation of the bronchi of allergic origin, which can occur at any age. Unfortunately, this disease cannot be completely cured, but it is possible to take control of it and live a full life. This is achieved by eliminating provoking factors and selecting optimal supportive treatment. It is for the selection of the minimum volume of medications, their dosage with maximum control of symptoms and progression of pathology that step-by-step therapy for bronchial asthma has been developed.

5 steps of asthma treatment GINA

The basic principles of this approach to treatment:

• selection of optimal drug treatment together with the patient and his relatives;
• continuous assessment of the clinical course of the disease and the level of its control;
• timely correction of therapy;
• if there is no clinical effect, move to a higher level;
• with complete control of the disease for 3 months. – move to a lower level;
• if in case of moderate bronchial asthma there was no basic therapy, then treatment begins from the 2nd stage;
• for uncontrolled disease, start from the 3rd stage;
• If necessary, emergency medications are used at any stage of treatment.

At each level, a therapeutic cycle is performed, which includes an assessment of the degree of control over the disease, a course of therapeutic measures aimed at achieving high control and monitoring the condition to maintain a period of remission.

Five steps of asthma therapy

Before starting therapy, the specialist determines the level of disease control based on an objective examination, analysis of complaints, frequency of exacerbations, and results of functional diagnostic methods. Thus, bronchial asthma can be:

• controlled - daytime attacks no more than 2 times a week, with the optional use of emergency treatment, no exacerbations, pulmonary function is not impaired, no exacerbations;
• partially controlled (persistent) – symptoms of the disease occur more than 2 times a week, including at night, require emergency treatment, exacerbations at least once a year, pulmonary function is reduced, activity is moderately impaired;
• uncontrolled (severe) – attacks occur day and night, can be repeated, activity is reduced, lung function is impaired, exacerbations occur every week.

Based on the degree of control, a certain level of therapy is selected. Each stage contains a variant of basic treatment and alternative. At any stage, the patient can use short-acting or long-acting rescue medications.

First stage

This level is suitable for patients with controlled bronchial asthma. Treatment includes the use of fast-acting beta2-agonists in inhaled form as needed (if an asthma attack develops). Alternative treatments include inhaled anticholinergics or oral short-acting beta2-agonists or theophyllines.

The same approach to treatment is used for bronchospasm, which is provoked by physical activity. Especially if this is the only manifestation of the disease. To prevent an attack, the drug is inhaled before or immediately after exercise.

Second stage

At this and subsequent levels, patients need to regularly use supportive care and rescue medications for attacks. At any age, it is permissible to prescribe low-dose hormonal drugs in inhalation form. If their use is not possible due to patient rejection, severe side effects, or chronic rhinitis, then antileukotriene drugs are prescribed as an alternative.

Third stage

Adult patients are prescribed a combination of a low-dose inhaled corticosteroid (ICS) and a long-acting beta2-agonist. The drugs can be used individually or as part of a combination dosage form. The combination of Budesonide and Formoterol is also suitable for relieving an acute attack of asthma.

Another treatment option is to increase the dosage of ICS to average values. It is recommended to use spacers to better deliver the drug and reduce side effects. In addition, for maintenance therapy it is possible to use ICS in conjunction with antileukotienes or slow theophylline.

Fourth stage

If control of the disease is not established at the previous level, then a complete examination of the patient is necessary to exclude another disease or establish a form of bronchial asthma that is difficult to treat. It is recommended, if possible, to consult a specialist who has extensive positive experience in treating this disease.

To establish control, combinations of inhaled hormones and long-acting beta2-agonists are chosen, with ICS prescribed in medium and high dosages. As an alternative, antileukotrienes or moderate doses of slow theophylline can be added to ICS in moderate doses.

Fifth stage

At this level, oral systemic hormonal drugs are added to the previous treatment. This choice helps to improve the patient’s condition and reduce the frequency of attacks, but causes severe side effects, about which the patient must be notified. As a treatment option, antibodies to immunoglobulin E can be used, which significantly increases the level of control over severe asthma.

Moving down a step

Monitoring the course of the disease should be carried out regularly at regular intervals. After prescribing therapy, control is carried out after 3 months, and in case of exacerbation after 1 month. During a visit to the doctor, the patient’s condition is assessed and the issue of the need to change the therapeutic level is decided.

A transition to a lower level is most likely possible from levels 2-3. At the same time, the dose of drugs and their quantity are gradually reduced (over 3 months); in the absence of deterioration, switch to monotherapy (stage 2). Then, if the outcome is good, only the emergency drug is left on demand (level 1). To move to a lower level, 1 year is required, during which the level of disease control remains high.

Features of stepwise treatment of asthma in children

In children of any age, therapy begins with the use of low-dose ICS (stage 2). If there is no effect within 3 months, a gradual increase in the dosage of the drugs is recommended (step 3). To relieve an acute attack, systemic hormonal drugs are prescribed in a short course in the minimum permissible doses.

To effectively control bronchial asthma in children, it is necessary to carefully teach the child (from 6 years of age) and parents how to use inhalers. In childhood and adolescence, the disease can be completely cured, so monitoring of the condition and dose adjustment should be carried out at least once every six months.

Conclusion

Stepped therapy for bronchial asthma allows you to achieve high control over the disease by prescribing a minimum amount of medications and constant monitoring of the patient's condition. It is important to observe the basic principles of this approach to treatment by both the specialist and the patient.