Asthma Attack Irrda 2017

Curriculum Vitae
DR. Dr. Arto Yuwono Soeroto, SpPD-KP, FCCP, FINASIM

E-mail: aysoeroto@yahoo.co.id
Pendidikan:
S1 FK Universitas Padjadjaran
Sp1 FK Universitas Padjadjaran
Konsultan Pulmonologi KIPD
S3 FK Universitas Padjadjaran
Pekerjaan:
Kepala Divisi Respirologi & Penyakit Kritis IPD FKUP/RS Hasan Sadikin
Ketua Tim TB RSUP Dr. Hasan Sadikin
Organisasi:
Ketua PB Perhimpunan Respirologi Indonesia (PERPARI)
Ketua Perhimpunan Dokter Spesialis Penyakit Dalam (PAPDI) Jabar (2009-2016)
Fellow American College of Chest Physcian (ACCP)
Fellow of Indonesian Society of Internal Medicine
European Respiratory Society (ERS)
MANAGEMENT OF ASTHMA
EXACERBATION
Arto Yuwono Soeroto

Divisi Respirologi dan Penyakit Kritis Respirasi
Departemen Ilmu Penyakit Dalam
FK Unpad – RS Hasan Sadikin
aysoeroto@yahoo.co.id
Definition and terminology
 A flare-up or exacerbation is an acute or sub-acute worsening

of symptoms and lung function compared with the patient’s
usual status
 Terminology
 ‘Flare-up’ is the preferred term for discussion with patients
 ‘Exacerbation’ is a difficult term for patients
 ‘Attack’ has highly variable meanings for patients and clinicians
 ‘Episode’ does not convey clinical urgency
 Consider management of worsening asthma as a continuum
 Self-management with a written asthma action plan
 Management in primary care
 Management in the emergency department and hospital
 Follow-up after any exacerbation
GINA 2017 © Global Initiative for Asthma

Acute Asthma/ Asthma Exacerbation
 PEF and FEV1 are more reliable indicators

of severity than degree of symptoms
 Degree of symptoms more sensitive
measure of onset of an exacerbation
 Different with uncontrolled/ poorly
controlled asthma  no diurnal variability
which in a key marker of uncontrolled
asthma
Clinician Treating Asthmatic Patients
 Be prepared to treat an asthma

exacerbation
 Recognized the signs and symptoms
of severe and life threatening
exacerbations
 Familiar with risk factors for asthma
related death
NAEPP 2009/GINA 2017
GINA 2012
Identify patients at risk of asthma-related death
 Patients at increased risk of asthma-related death should be

identified
 Any history of near-fatal asthma requiring intubation and ventilation
 Hospitalization or emergency care for asthma in last 12 months
 Not currently using ICS, or poor adherence with ICS
 Currently using or recently stopped using OCS
• (indicating the severity of recent events)
 Over-use of SABAs, especially if more than 1 canister/month
 Lack of a written asthma action plan
 History of psychiatric disease or psychosocial problems
 Confirmed food allergy in a patient with asthma
 Flag these patients for more frequent review
GINA 2017, Box 4-1 © Global Initiative for Asthma

MANAGEMENT OF ACUTE
ASTHMA
(as continuum)
 Self management with written asthma
action Plan
 Management in Primary Care
 Management in Emergency Department
and Hospital
 Follow up after exacerbations
Written asthma action plans – medication options
 Increase inhaled reliever

 Increase frequency as needed
 Adding spacer for pMDI may be helpful
 Early and rapid increase in inhaled controller
 Up to maximum ICS of 2000mcg BDP/day or equivalent
 Options depend on usual controller medication and type of LABA
 See GINA 2017 report Box 4-2 for details
 Add oral corticosteroids if needed
 Adults: prednisolone 1mg/kg/day up to 50mg, usually 5-7 days
 Children: 1-2mg/kg/day up to 40mg, usually 3-5 days
 Morning dosing preferred to reduce side-effects UPDATED
2017
 Tapering not needed if taken for less than 2 weeks
 Remember to advise patients about common side-effects (sleep
disturbance, increased appetite, reflux, mood changes)
GINA 2017, Box 4-2 (2/2) © Global Initiative for Asthma

PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?
LIFE-THREATENING
Drowsy, confused
or silent chest
URGENT
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA and
ipratropium bromide, O2, systemic
corticosteroid

Is it asthma?
MILD or MODERATE SEVERE

Talks in phrases, prefers Talks in words, sits hunched LIFE-THREATENING
sitting to lying, not agitated forwards, agitated Drowsy, confused
Respiratory rate increased Respiratory rate >30/min or silent chest
Accessory muscles not used Accessory muscles in use
Pulse rate 100–120 bpm Pulse rate >120 bpm
O2 saturation (on air) 90–95% O2 saturation (on air) <90%
PEF >50% predicted or best PEF ≤50% predicted or best URGENT
TRANSFER TO ACUTE
CARE FACILITY
ipratropium bromide, O2, systemic
corticosteroid

Is it asthma?

Talks in phrases, prefers Talks in words, sits hunched LIFE-THREATENING
sitting to lying, not agitated forwards, agitated Drowsy, confused
Respiratory rate increased Respiratory rate >30/min or silent chest
Accessory muscles not used Accessory muscles in use
O2 saturation (on air) 90–95% O2 saturation (on air) <90%
PEF >50% predicted or best PEF ≤50% predicted or best URGENT
START TREATMENT
TRANSFER TO ACUTE
SABA 4–10 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING While waiting: give inhaled SABA and
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg ipratropium bromide, O2, systemic
Controlled oxygen (if available): target corticosteroid
saturation 93–95% (children: 94-98%)

START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
Prednisolone: adults 1 mg/kg, max. WORSENING
CONTINUE TREATMENT with SABA as needed

WORSENING
ASSESS RESPONSE AT 1 HOUR (or earlier)
IMPROVING
ASSESS FOR DISCHARGE

Symptoms improved, not needing SABA
PEF improving, and >60-80% of personal
best or predicted
Oxygen saturation >94% room air
Resources at home adequate

START TREATMENT

WORSENING
IMPROVING
ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

Symptoms improved, not needing SABA Reliever: continue as needed
PEF improving, and >60-80% of personal Controller: start, or step up. Check inhaler technique,
best or predicted adherence
Oxygen saturation >94% room air Prednisolone: continue, usually for 5–7 days
(3-5 days for children)
Follow up: within 2–7 days

START TREATMENT
While waiting: give inhaled SABA
50 mg, children 1–2 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid

WORSENING
IMPROVING
ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

Symptoms improved, not needing SABA Reliever: continue as needed
PEF improving, and >60-80% of personal Controller: start, or step up. Check inhaler technique,
best or predicted adherence
Oxygen saturation >94% room air Prednisolone: continue, usually for 5–7 days
(3-5 days for children)
Follow up: within 2–7 days
FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (1–2 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?

MANAGEMENT IN EMERGENCY
DEPARTEMENT AND HOSPITAL
TREATMENT
Oxygen
 Achieve SpO2 > 93 - 95%
 In pregnant women and CAD SpO2 >95%
 Nasal cannule or mask
 Titrated against pulse oximetry to
maintain SpO2 level as above
 Beware of worsening CO2
TREATMENT
short acting inhaled B2 agonist (SABA)
 Administered at regular interval
 Intermittent on demand VS intermittent therapy
every 4 hours
- Shorter hospital stay
- Fewer nebulization
- Fewer palpitation
 Reasonable approach  Initial use of continous
therapy followed by on demand
 No evidence support the use routine iv B2 agonist
Bricasma® Respules (SABA)
Pasien Eksaserbasi Asma di IGD
Rapid Bronchodilator
Bricasma® Respules
mempunyai efek yang cepat
sebagai bronkodilator
Studi acak, tersamar ganda, crossover pada 21 pasien asma atopik ringan – sedang
membandingkan efikasi inhalasi terbutaline 5 mg tanpa preservative, terbutaline 5
mg dengan preservative dan plasebo.
Lai CKW et al. Effect of preservative on the efficacy of terbutaline nebuliser solution in atopic asthma. Thorax; 1993; 48: 566-568
Efektif Meningkatkan nilai FEV1 dan PEF
Kombinasi Bricasma Respules dan ipratropium bromide efektif untuk
meningkatkan nilai FEV1 dan PEF secara signifikan
**
**
FEV1: Force Expiratory Volume in 1 second

PEF: Peak Expiratory Flow
** p<0.01 vs sebelum terapi

Penelitian terdiri atas 11 pasien dengan rata-rata umur 65 tahun yang datang ke IGD dengan kasus asma akut, semua pasien diterapi dengan 5 mg terbutaline (0.05-0.11 mg/kg) (Bricamyl
Astra) dan 0.5 mg ipratropium bromide. Terapi diberikan dengan menggunakan Nebulizer dengan volume 4 ml. Semua pasien mendapatkan terapi betamethasone intravena dan peniliaian
dilakukan sebelum terapi, 60 menit dan 120 setelah terapi
Janson C, Herala M. Plasma terbutaline levels in nebulisation treatment of acute asthma. Paulmonary Pharmacology (1991) 4, 135-1392
Well Tolerated
Kombinasi Bricasma® Respules dan Ipratropium Bromide tidak meningkatkan
denyut nadi dan tremor pasien setelah terapi
Penelitian terdiri atas 11 pasien dengan rata-rata umur 65 tahun yang datang ke IGD dengan kasus asma akut, semua pasien diterapi dengan 5 mg terbutaline (0.05-0.11 mg/kg) (Bricamyl
Astra) dan 0.5 mg ipratropium bromide. Terapi diberikan dengan menggunakan Nebulizer dengan volume 4 ml. Semua pasien mendapatkan terapi betamethasone intravena dan peniliaian
dilakukan sebelum terapi, 60 menit dan 120 setelah terapi
Janson C, Herala M. Plasma terbutaline levels in nebulisation treatment of acute asthma. Paulmonary Pharmacology (1991) 4, 135-139
TREATMENT MODALITIES
Epinephrine
 Not routinely indicated in asthma
exacerbation
 Indicated for acute treatment of
anaphylaxis and angiodema
 0.3 – 0.5 mg every 20 min for 3 doses
 No proven advantage for routine use
IPRATROPIUM BROMIDE (IB)
 Rationale: increase airway vagal tone in acute
asthma
 Inferior than B2 agonist in improving airflow
limitation if used as a single initial treatment
 Combination of IB and B2 agonist resulted in
◦ Reduction in hospitalization
◦ Significant improvement in lung function
◦ Total treatment cost reductions
IPRATROPIUM BROMIDE (IB)
 The independent benefit of the anticholinergic is
constant with the proposal that muscarinic
receptor are described in the large airway and B2
receptor are mainly in the small airways
 Patient treated with IB+B2 agonist had FEV1
increase regardless of their previous use of B2
agonist
 500 mg per dose every 20 minutes in nebulized
form or 4 puff (80mg) every 10-20 minutes via MDI
with spacer in combination with B2 agonist
THEOPHYLLINE
 Due to effectiveness and relative safety of B2
agonist rapid acting  causing minimal role of
theophylline in management of acute asthma
 Bronchodilator effect less than B2 agonist
 Severe and potentially fatal side effect
 Add on treatment
 Bolus 6 mg/kg iv slow, continued with infusion 0,3-
0,6 mg/kg/hour
 Monitoring blood level
SYSTEMIC CORTICOSTEROID
 Speed resolution of exacerbation  utilized in
all exacerbation
 Especially if
◦ Initial SABA fails to achieve lasting improvement
◦ Exacerbation develop even when talking oral
corticosteroid
◦ Previous exacerbation requires oral corticosteroid
 Oral corticosteroid is as effective as
intravenous
SYSTEMIC CORTICOSTEROID
 Manser R (2000)
◦ 60-80 mg methylprednisolone (MP) as a single dose
◦ 300-400 mg hydrocortisone in divided dose
 Rowe B. H. (2000)
◦ 40 mg MP or 200 mg hydrocortisone
 7 days course similar result with 14 days course
 No benefits to tappering the dose
INHALED CORTICOSTEROID
 Combination of high dose inhaled
corticosteroid + salbutamol provide
greater bronchodilatation than salbutamol
alone
 As effective as oral corticosteroid in
preventing relapses after ED discharged
 2,4 mg budesonide daily in four divided
dose achieve relapse rate similar to 40 mg
oral prednisolone daily
Triple Inhaled Drug Protocol
 Albuterol (A)plus Ipratroprium Bromide
(IB) plus Flunisolide (F)  (TDG)
 TDG compared with A/F or A/IB
 Suggest that there was a theurapeutic
benefit from the addition of IB and F to A
administered in high dose particularly in
those patients in whom the FEV1 was <
30% of the predicted value
Rodrigo GJ. Chest 2003; 123: 1908 - 1915

Pulmicort® Respules
Pasien Eksaserbasi Asma
Efikasi Setara dengan Oral Prednisolone
Terapi selama 5 hari dengan

Pulmicort respules mempunyai
Rata-rata PEF
efikasi yang setara (PEF) dengan

oral prednisolone pada pasien
asma dewasa dengan eksaserbasi
Pulmicort Respules
Oral Prednisolone
Hari
Penelitian retrospective pada 28 pasien rawat inap dengan asma eksaserbasi ringan-berat dari Januari-Desember 2003. Pasien ini sudah tidak menggunakan steroid ≥1
tahun, terapi yang diberikan adalah budesonide inhalation suspension (BIS) 2 x 2 mg bid atau oral prednisolone (OP) 2 x 15 mg bid. Parameter yang diukur adalah PEF,
FEV1 dan skor gejala asma yang dicatat per hari.
Chian CF et al. Five-day course of budesonide inhalation suspension is as effective as oral prednisolone in the treatment of mild to severe acute asthma exacerbations in adults. Pulmonary
Pharmacology & Therapeutics 24 (2011) 256e260
Menurunkan Durasi Rawat Inap
Penambahan Pulmicort Respules

pada terapi standar mampu
menurunkan durasi rawat inap
secara bermakna pada pasien asma
anak (dan juga total biaya
perawatan) dibandingkan dengan
plasebo
Penelitian di 1 center, acak, buta ganda, paralel menggunakan kontrol plasebo. Pasien anak usia 7 -72 bulan dengan eksaserbasi asma yang dirawat di rumah sakit, clinical
asthma score (CAS) antara 3 and 9 diacak untuk mendapatkan budesonide inhalasi 2 mg/hari (n = 50) atau plasebo (n = 50) sebagai tambahan pada terapi asma standard
yang meliputi inhalasi oksigen, β2 -agonist, antikolinergik and kortikosteroid oral. Lama perawatan di rumah sakit dibandingkan antara kelompok budesonide versus
plasebo.
Razi CH et al. The Addition of Inhaled Budesonide to Standard Therapy Shortens the Length of Stay in Hospital for Asthmatic Preschool Children: A Randomized, Double-Blind, Placebo-
Controlled Trial. Int Arch Allergy Immunol 2015;166:297–303
Higher Night Symptom Free vs Fluticasone
P=0.006
P=0.074 Penambahan Pulmicort

Respules 500 mcg pada
inhalasi SABA terhadap pasien
anak dengan serangan asma
ringan selama 10 hari mampu
menurunkan gejala asma
malam hari secara signifikan
bila dibandingkan dengan
Fluticasone Propionate 250
mcg
Penelitian multi center, acak, tersamar tunggal, paralel. 168 pasien anak dengan eksaserbasi asma ringan usia 4-15 tahun diacak untuk mendapatkan inhalasi fluticasone
propionate (FP 250 mcg) atau inhalasi budesonide (BUD 500 mcg) 2x/ hari sebagai terapi tambahan pada inhalasi salbutamol selama 10 hari. Penilaian klinis dan
pengukuran fungsi paru dilakukan saat kunjungan pertama, akhir terapi dan 7 hari follow up. Skor asma siang hari dan malam hari, penggunaan rescue salbutamol, peak
expiratory flow (PEF) pagi/ sore dicatat selama terapi.
Benedictis FM et all. Nebulized Fluticasone Propionate vs. Budesonide as Adjunctive Treatment in Children with Asthma Exacerbation. Journal of Asthma; 2005 (42):331–336.
MAGNESIUM
 Not recommended for routine use in asthma
exacerbation
 Reduces hospital admission rate in
◦ Adult with FEV1 25-30% predicted/best
◦ Fail to respond to initial treatment
◦ FEV1 fail to improve to > 60% after I hour
 Usually single 1,2 – 2 mg MgSO4 infusion over
20 minutes
 Nebulized salbutamol in isotonic Mg (2,5 cc)
provide greater benefit than if it delivered in
normal saline
HELIUM OXYGEN THERAPY
 Turbulensi aliran udara pada asma akut
◦ Tahanan saluran napas ↑  kerja napas ↑ 
hiperinflasi dinamik ↑
◦ Pencapaian partikel aerosol ke saluran napas lebih sulit
◦ Turbulensi dapat di turunkan dengan pemberian gas
dengan densitas lebih rendah dan viskositas lebih tinggi
dibanding udara
 Campuran helium dan oksigen (heliox) 80/20, 70/30
atau 60/40  mengurangi tahanan saluran napas,
hiperinflasi dan memperbaiki deposit nebulisasi
bronkhodilator
 Leukotrine modifier
◦ Still little data
◦ Two studies of zafirlukast PO and montelukast
IV demonstrated improvement in lung
function and dyspnea score in acute asthma
refracter to initial B2 agonist therapy
 Sedatives
◦ Strictly avoided during asthma exacerbation
due to respiratory depressant effect
Managing exacerbations in acute care settings
INITIAL ASSESSMENT Are any of the following present?

A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest
NO
YES
Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation
Talks in phrases Talks in words

Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
O2 saturation (on air) 90–95% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF ≤50% predicted or best
Short-acting beta2-agonists Short-acting beta2-agonists

Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 93–95% (children 94-98%) saturation 93–95% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
If continuing deterioration, treat as

severe and re-aassess for ICU
ASSESS CLINICAL PROGRESS FREQUENTLY

MEASURE LUNG FUNCTION
in all patients one hour after initial treatment
FEV1 or PEF 60-80% of predicted or FEV1 or PEF <60% of predicted or

personal best and symptoms improved personal best,or lack of clinical response
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning and reassess frequently

INITIAL ASSESSMENT Are any of the following present?
A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest
NO
YES
Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation




If continuing deterioration, treat as

severe and re-assess for ICU
ASSESS CLINICAL PROGRESS FREQUENTLY

MEASURE LUNG FUNCTION
in all patients one hour after initial treatment
FEV1 or PEF <60% of predicted or

FEV1 or PEF 60-80% of predicted or
personal best,or lack of clinical response
personal best and symptoms improved
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning
and reassess frequently

TERIMA KASIH
Written asthma action plans
 All patients should have a written asthma action plan

 The aim is to show the patient how to recognize and respond to
worsening asthma
 It should be individualized for the patient’s medications, level of
asthma control and health literacy
 Based on symptoms and/or PEF (children: only symptoms)
 The action plan should include:
 The patient’s usual asthma medications
 When/how to increase reliever and controller or start OCS
 How to access medical care if symptoms fail to respond
 Why?
 When combined with self-monitoring and regular medical review,
action plans are highly effective in reducing asthma mortality and
morbidity
GINA 2017 © Global Initiative for Asthma

Follow-up after an exacerbation
 Follow up all patients regularly after an exacerbation, until

symptoms and lung function return to normal
 Patients are at increased risk during recovery from an exacerbation
 The opportunity
 Exacerbations often represent failures in chronic asthma care,
and they provide opportunities to review the patient’s asthma
management
 At follow-up visit(s), check:
 The patient’s understanding of the cause of the flare-up
 Modifiable risk factors, e.g. smoking
 Adherence with medications, and understanding of their purpose
 Inhaler technique skills
 Written asthma action plan
GINA 2017, Box 4-5 © Global Initiative for Asthma

ASSESSMENT
Physical examination
Asses exacerbation severity
 Ability to complete sentence
 Pulse rate
 RR
 Use of accessory muscle
Identified any complicating factors
 Pneumonia
 Atelectasis
 Pneumothorax
 Pneumomediastinum
ASSESSMENT
 PEF or FEV1
 Arterial Oxygen Saturation
 CXR  not routine  if complicating
cardiopulmonary process suspected
 BGA  not routine
- PEF 30-50% predicted
- Not responding to initial treatment
- Deterioration

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Curriculum Vitae

DR. Dr. Arto Yuwono Soeroto, SpPD-KP, FCCP, FINASIM

Arto Yuwono Soeroto

 A flare-up or exacerbation is an acute or sub-acute worsening

GINA 2017 © Global Initiative for Asthma

 PEF and FEV1 are more reliable indicators

 Be prepared to treat an asthma

 Patients at increased risk of asthma-related death should be

GINA 2017, Box 4-1 © Global Initiative for Asthma

 Increase inhaled reliever

GINA 2017, Box 4-2 (2/2) © Global Initiative for Asthma

GINA 2017, Box 4-3 (2/7) © Global Initiative for Asthma

MILD or MODERATE SEVERE

GINA 2017, Box 4-3 (3/7) © Global Initiative for Asthma

MILD or MODERATE SEVERE

GINA 2017, Box 4-3 (4/7) © Global Initiative for Asthma

CONTINUE TREATMENT with SABA as needed

ASSESS FOR DISCHARGE

GINA 2017, Box 4-3 (5/7) © Global Initiative for Asthma

CONTINUE TREATMENT with SABA as needed

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

GINA 2017, Box 4-3 (6/7) © Global Initiative for Asthma

CONTINUE TREATMENT with SABA as needed

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

GINA 2017, Box 4-3 (7/7) © Global Initiative for Asthma

FEV1: Force Expiratory Volume in 1 second

** p<0.01 vs sebelum terapi

Rodrigo GJ. Chest 2003; 123: 1908 - 1915

Terapi selama 5 hari dengan

efikasi yang setara (PEF) dengan

Penambahan Pulmicort Respules

P=0.074 Penambahan Pulmicort

INITIAL ASSESSMENT Are any of the following present?

MILD or MODERATE SEVERE

Talks in phrases Talks in words

Short-acting beta2-agonists Short-acting beta2-agonists

If continuing deterioration, treat as

ASSESS CLINICAL PROGRESS FREQUENTLY

FEV1 or PEF 60-80% of predicted or FEV1 or PEF <60% of predicted or

GINA 2017, Box 4-4 (1/4) © Global Initiative for Asthma

MILD or MODERATE SEVERE

GINA 2017, Box 4-4 (2/4) © Global Initiative for Asthma

Short-acting beta2-agonists Short-acting beta2-agonists

GINA 2017, Box 4-4 (3/4) © Global Initiative for Asthma

If continuing deterioration, treat as

ASSESS CLINICAL PROGRESS FREQUENTLY

FEV1 or PEF <60% of predicted or

GINA 2017, Box 4-4 (4/4) © Global Initiative for Asthma

 All patients should have a written asthma action plan

GINA 2017 © Global Initiative for Asthma

 Follow up all patients regularly after an exacerbation, until

GINA 2017, Box 4-5 © Global Initiative for Asthma

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