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112 Pages·2010·0.86 MB·English

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GlobalStrategyforAsthmaManagementandPrevention
TheGINAreportsareavailableonwww.ginasthma.org.
Global Strategy for Asthma Management and Prevention 2009 (update)
GINAEXECUTIVECOMMITTEE* GINASCIENCECOMMITTEE*
EricD.Bateman,MD,Chair MarkFitzGerald,MD,Chair
UniversityCapeTownLungInstitute UniversityofBritishColumbia
CapeTown,SouthAfrica Vancouver,BC,Canada !
E
C
Louis-PhilippeBoulet, MD NeilBarnes,MD
HôpitalLaval LondonChestHospital U
Sainte-Foy,Quebec,Canada London,England,UK
D
AlvaroA.Cruz,MD PeterJ.Barnes,MD O
FederalUniversityofBahia NationalHeartandLungInstitute R
SchoolofMedicine London,England,UK
P
Salvador,Brazil
EricD.Bateman,MD E
MarkFitzGerald,MD UniversityCapeTownLungInstituteR
UniversityofBritishColumbia CapeTown,SouthAfrica

Vancouver,BC,Canada R
AllanBecker,MD O
TariHaahtela,MD UniversityofManitoba
HelsinkiUniversityCentralHospital Winnipeg,Manitoba,CaRn ada
Helsinki,Finland
JeffreyM.Drazen,MED
MarkL.Levy,MD HarvardMedicalSTchool
UniversityofEdinburgh Boston,MassaLchusetts,USA
LondonEngland,UK A
RobertF.Lemanske,Jr.,M.D.

PaulO'Byrne,MD UniversiTtyofWisconsin
McMasterUniversity SchooOlofMedicine
Ontario,Canada Madison,Wisconsin,USA
N
KenOhta,MD,PhD PaulO'Byrne,MD
O
TeikyoUniversitySchoolofMedicine McMasterUniversity
Tokyo,Japan D Ontario,Canada

PierluigiPaggiaro,MD - KenOhta,MD,PhD

UniversityofPisa L TeikyoUniversitySchoolofMedicine
Pisa,Italy A Tokyo,Japan
I
SorenErikPedersen,M.D. R SorenErikPedersen,M.D.
KoldingHospital E KoldingHospital
Kolding,Denmark Kolding,Denmark
T
A
ManuelSoto-Quiroz,MD EmilioPizzichini,MD
HospitalNacionaldeNiños M UniversidadeFederaldeSantaCatarina
SanJosé,CostaRica Florianópolis,SC,Brazil

D
GaryW.Wong,MD E HelenK.Reddel,MD
ChineseUniversityofHongKong WoolcockInstituteofMedicalResearch
T
HongKongROC Camperdown,NSW,Australia
H
G SeanD.Sullivan,PhD
ProfessorofPharmacy,PublicHealth
I
R UniversityofWashington
Seattle,Washington,USA
Y
P
SallyE.Wenzel,M.D.
O UniversityofPittsburgh
Pittsburgh,Pennsylvania,USA
C
HeatherJ.Zar,MD
UniversityofCapeTown
CapeTown,SouthAfrica
i
*DisclosuresformembersofGINAExecutiveandScienceCommitteescanbefoundat:
http://www.ginasthma.com/Committees.asp?l1=7&l2=2
PREFACE
Asthmaisaseriousglobalhealthproblem. Peopleofall Inspiteofthesedisseminationefforts,international
agesincountriesthroughouttheworldareaffectedbythis surveysprovidedirectevidenceforsuboptimalasthma
chronicairwaydisorderthat,whenuncontrolled,canplace controlinmanycountries,despitetheavailabilityof
severelimitsondailylifeandissometimesfatal. The effectivetherapies. Itisclearthatifrecommendations!
E
prevalenceofasthmaisincreasinginmostcountries, containedwithinthisreportaretoimprovecareofpeople
C
especiallyamongchildren. Asthmaisasignificantburden, withasthma,everyeffortmustbemadetoencourage
U
notonlyintermsofhealthcarecostsbutalsooflost healthcareleaderstoassureavailabilityofandaccessto
D
productivityandreducedparticipationinfamilylife. medications,anddevelopmeanstoimplementeffective
O
asthmamanagementprogramsincludingtheuseof
Duringthepasttwodecades,wehavewitnessedmany R
appropriatetoolstomeasuresuccess.
scientificadvancesthathaveimprovedourunderstanding P
ofasthmaandourabilitytomanageandcontrolit In2002,theGINAReportstatedtEhat“itisreasonableto
effectively. However,thediversityofnationalhealthcare expectthatinmostpatientswitRhasthma,controlofthe
servicesystemsandvariationsintheavailabilityofasthma diseasecan,andshouldbeR achievedandmaintained.”
therapiesrequirethatrecommendationsforasthmacare Tomeetthischallenge,Oin2005,ExecutiveCommittee
beadaptedtolocalconditionsthroughouttheglobal recommendedprepa rationofanewreportnotonlyto
community. Inaddition,publichealthofficialsrequire R
incorporateupdatedscientificinformationbuttoimplement
informationaboutthecostsofasthmacare,howto E
anapproachtoasthmamanagementbasedonasthma
effectivelymanagethischronicdisorder,andeducation T
control,ratherthanasthmaseverity. Recommendationsto
L
methodstodevelopasthmacareservicesandprograms
assess,treAatandmaintainasthmacontrolareprovidedin
responsivetotheparticularneedsandcircumstances
thisdoc ument. Themethodsusedtopreparethis
withintheircountries. T
documentaredescribedintheIntroduction.
O
In1993,theNationalHeart,Lung,andBloodInstitute N
Itisaprivilegeformetoacknowledgetheworkofthe
collaboratedwiththeWorldHealthOrganizationto
O manypeoplewhoparticipatedinthisupdateproject,as
conveneaworkshopthatledtoaWorkshopReport:
D wellastoacknowledgethesuperlativeworkofallwho
GlobalStrategyforAsthmaManagementandPrevention.
havecontributedtothesuccessoftheGINAprogram.
Thispresentedacomprehensiveplantomanageasthm-a

withthegoalofreducingchronicdisabilityandpremaLture
TheGINAprogramhasbeenconductedthrough
A
deathswhileallowingpatientswithasthmatolead
unrestrictededucationalgrantsfromAstraZeneca,
I
productiveandfulfillinglives. R
BoehringerIngelheim,ChiesiGroup,GlaxoSmithKline,
E
MedaPharma,Merck,Sharp&Dohme,MitsubishiTanabe
Atthesametime,theGlobalInitiativeforTAsthma(GINA)
Pharma,Novartis,Nycomed,PharmAxisandSchering-
wasimplementedtodevelopanetworkAofindividuals,
Plough. Thegenerouscontributionsofthesecompanies
organizations,andpublichealthofficMialstodisseminate
assuredthatCommitteememberscouldmeettogetherto
informationaboutthecareofpat ientswithasthmawhileat
D discussissuesandreachconsensusinaconstructiveand
thesametimeassuringamechanismtoincorporatethe
E timelymanner. ThemembersoftheGINACommittees
resultsofscientificinvestigationsintoasthmacare.
T are,however,solelyresponsibleforthestatementsand
PublicationsbasedontheGINAReportwereprepared
H conclusionspresentedinthispublication.
andhavebeentranslatedintolanguagestopromote
G
internationalcollaborationanddisseminationof
I GINApublicationsareavailablethroughtheInternet
information. TodRisseminateinformationaboutasthma
(http://www.ginasthma.org).
care,aGINAAYssemblywasinitiated,comprisedofasthma
careexpertPsfrommanycountriestoconductworkshops
withlocaOldoctorsandnationalopinionleadersandtohold
seminCarsatnationalandinternationalmeetings. In
addition,GINAinitiatedanannualWorldAsthmaDay(in
2001)whichhasgainedincreasingattentioneachyearto
raiseawarenessabouttheburdenofasthma,andto EricBateman,MD
initiateactivitiesatthelocal/nationalleveltoeducate Chair,GINAExecutiveCommittee
familiesandhealthcareprofessionalsabouteffective UniversityofCapeTownLungInstitute
methodstomanageandcontrolasthma. CapeTown,SouthAfrica
ii
GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION
TABLE OF CONTENTS
PREFACE.........................................................................ii CLINICALDIAGNOSIS...................................................16
MedicalHistory...........................................................16
METHODOLOGYANDSUMMARYOFNEW Symptoms..............................................................16
!
RECOMMENDATION,2007UPDATE.........................vi Coughvariantasthma......................................E......16
Exercise-Inducedbronchospasm.................C..........17
INTRODUCTION..............................................................x PhysicalExamination...................................U..............17
TestsforDiagnosisandMonitoring.........D...................17
CHAPTER1. DEFINITIONANDOVERVIEW..................1 Measurementsoflungfunction........O.......................17
Spirometry..................................R............................18
KEYPOINTS....................................................................2 Peakexpiratoryflow...............P................................18
MeasurementofairwayrespEonsiveness................19
DEFINITION.....................................................................2
Non-InvasivemarkersofRairwayinflammation........19
Measurementsofaller gicstatus.............................19
THEBURDENOFASTHMA.............................................3 R
Prevalence,MorbidityandMortality.............................3 O
DIAGNOSTICCHALLENGESAND
SocialandEconomicBurden.......................................3
DIFFERENTIALDRIAGNOSIS.......................................20
Children5YeEarsandYounger...................................20
FACTORSINFLUENCINGTHE DEVELOPMENTAND
OlderChildTrenandAdults..........................................20
EXPRESSIONOFASTHMA..........................................4
TheEldeLrly.................................................................21
HostFactors................................................................4 A
OccupationalAsthma.................................................21
Genetic.....................................................................4
DisTtinguishingAsthmafromCOPD............................21
Obesity.....................................................................5
O
Sex...........................................................................5
CNLASSIFICATIONOFASTHMA.....................................22
EnvironmentalFactors................................................5
Etiology......................................................................22
Allergens..................................................................5 O
Phenotype..................................................................22
Infections..................................................................5D
AsthmaControl..........................................................22
Occupationalsensitizers........................................ ...5
- AsthmaSeverity.........................................................23
Tobaccosmoke................................................. .......6
L
Outdoor/Indoorairpollution......................................6
A
REFERENCES...............................................................23
Diet...........................................................................7
I
R
MECHANISMSOFASTHMA......................E......................7 CHAPTER3.ASTHMAMEDICATIONS........................27
AirwayInflammationInAsthma..........T..........................7
Inflammatorycells......................A..............................7 KEYPOINTS..................................................................28
M
Inflammatorymediators............................................7
StructuralchangesintheDa irways.............................8 INTRODUCTION............................................................28
Pathophysiology...........................................................8
E
Airwayhyperresponsiveness....................................8 ASTHMAMEDICATIONS:ADULTS...............................28
T
SpecialMechanismsH....................................................8 RouteofAdministration..............................................28
AcuteexacerbaGtions.................................................8 ControllerMedications................................................29
Nocturnalasthma.....................................................9 Inhaledglucocorticosteroids...................................29
I
IrreversibleRairflowlimitation.....................................9 Leukotrienemodifiers.............................................30
Difficult-Yto-treatasthma............................................9 Long-actinginhaled(cid:1)-agonists.............................30
2
SmokPingandasthma................................................9 Theophylline...........................................................31
O
Cromones:sodiumcromoglycateand
REFECRENCES.................................................................9 nedocromilsodium........................................31
Long-actingoral(cid:1)-agonists...................................32
2
CHAPTER2. DIAGNOSISANDCLASSIFICATION.....15 Anti-IgE..................................................................32
Systemicglucocorticosteroids................................32
KEYPOINTS..................................................................16 Oralanti-allergiccompounds..................................32
INTRODUCTION............................................................16 Othercontrollertherapies.......................................32
Allergen-specificimmunotherapy............................33
iii
RelieverMedications...................................................34
Rapid-actinginhaled(cid:1)-agonists............................34 ASTHMAPREVENTION.................................................54
2
Systemicglucocorticosteroids................................34
Anticholinergics......................................................34 PREVENTIONOFASTHMASYMPTOMSAND
Theophylline...........................................................35 EXACERBATIONS....................................................55
Short-actingoral(cid:1)2-agonists..................................35 IndoorAllergens .......................................................55
ComplementaryandAlternativeMedicine...................35 Domesticmites...................................................!....55
E
Furredanimals.......................................................55
C
ASTHMATREATMENT: CHILDREN.............................35 Cockroaches..........................................................55
U
RouteofAdministration..............................................35 Fungi......................................................................56
D
ControllerMedications................................................36 OutdoorAllergens......................................................56
O
Inhaledglucocorticosteroids...................................36 IndoorAirPollutants ..................................................56
R
Leukotrienemodifiers.............................................38 OutdoorAirPollutants................................................56
Long-actinginhaled(cid:1)-agonists.............................38 OccupationalExposures............P................................56
2
E
Theophylline...........................................................39 FoodandFoodAdditives...........................................56
R
Cromones:sodiumcromoglycateandnedocromil Drugs.........................................................................57

sodium .........................................................39 InfluenzaVaccination...R..............................................57
Long-actingoral(cid:1)2-agonists...................................39 Obesity....................O...................................................57
Systemicglucocorticosteroids................................39 EmotionalStress ........................................................57
R
RelieverMedications...................................................40 OtherFactorsThatMayExacerbateAsthma.............57
E
Rapid-actinginhaled(cid:1)-agonistsandshort-acting
2 T
oral(cid:1)2-agonists..............................................40 COMPONELNT3: ASSESS,TREATANDMONITOR
Anticholinergics......................................................40 ASTHMAA......................................................................57

T
REFERENCES...............................................................40 KEYPOINTS..................................................................57
O
N
CHAPTER4. ASTHMAMANAGEMENTAND INTRODUCTION............................................................57

PREVENTION................................................................49 O
D ASSESSINGASTHMACONTROL.................................58
INTRODUCTION........................................................... .50
-
L TREATINGTOACHIEVECONTROL.............................58
COMPONENT1: DEVELOP PATIENT/ A TreatmentStepsforAchievingControl........................58
DOCTORPARTNERSHIP.............................I..............50 Step1: As-neededrelievermedication..................58
R
Step2: Relievermedicationplusasingle
E
KEYPOINTS..................................................................50 controller.........................................................60
T
A Step3: Relievermedicationplusoneortwo
INTRODUCTION............................M................................50 controllers.......................................................60
Step4: Relievermedicationplustwoormore

ASTHMAEDUCATION............D.......................................51 controllers.......................................................61
AttheInitialConsultationE...........................................52 Step5: Relievermedicationplusadditional
PersonalAsthmaActioTnPlans..................................52 controlleroptions............................................61
H
Follow-upandReview...............................................52
G
ImprovingAdherence................................................52 MONITORINGTOMAINTAINCONTROL......................61
Self-ManageRmIentinChildren....................................52 DurationandAdjustmentstoTreatment......................61
Y SteppingDownTreatmentWhenAsthmaIs
THEEDUCPATIONOFOTHERS.....................................53 Controlled.................................................................62
O SteppingUpTreatmentInResponseToLossOf
COMPCONENT2: IDENTIFYANDREDUCEEXPOSURE Control.....................................................................62
TORISKFACTORS....................................................54 Difficult-to-Treat-Asthma.............................................63
KEYPOINTS..................................................................54
COMPONENT4-MANAGEASTHMA
INTRODUCTION............................................................54 EXACERBATIONS......................................................64
iv
UtilizationandCostofHealthCareResources.........89
KEYPOINTS..................................................................64 DeterminingtheEconomicValueofInterventionsin
Asthma...................................................................90
INTRODUCTION............................................................64
GINADISSEMINATION/IMPLEMENTATION
ASSESSMENTOFSEVERITY.......................................65 RESOURCES............................................................90
!
E
MANAGEMENT–COMMUNITYSETTINGS...................65 REFERENCES...............................................................91
C
Treatment...................................................................66
U
Bronchodilators......................................................66
D
Glucocorticosteroids...............................................66
O
R
MANAGEMENT–ACUTECARESETTINGS..................66
P
Assessment................................................................66
E
Treatment....................................................................68
R
Oxygen...................................................................68

Rapid-actinginhaled(cid:1)–agonists...........................68 R
2
Epinephrine............................................................68 O
Additionalbronchodilators...........................................68
R
Systemicglucocorticosteroids................................68
E
Inhaledglucocorticosteroids...................................69
T
Magnesium.............................................................69
L
Heliumoxygentherapy...........................................69 A
Leukotrienemodifiers.............................................69
T
Sedatives...............................................................69
O
CriteriaforDischargefromtheEmergency
N
Departmentvs.Hospitalization.................................69

O
COMPONENT5. SPECIALCONSIDERATIONS..........70D
Pregnancy.................................................................... .70
-

Surgery..................................................................L.......70
Rhinitis,Sinusitis,AndNasalPolyps...................A..........71
Rhinitis...................................................R..I..............71
Sinusitis..................................................................71
E
Nasalpolyps...................................T........................71
OccupationalAsthma........................A............................71
RespiratoryInfections...................M................................72
GastroesophagealReflux......... .....................................72
D
Aspirin-InducedAsthma................................................72
E
AnaphylaxisandAsthma...............................................73
T
H
REFERENCES...............................................................73
G
I
CHAPTER5. IMRPLEMENTATIONOFASTHMA
GUIDELINEYSINHEALTHSYSTEMS.........................87
P
KEYPOOINTS..................................................................88
C
INTRODUCTION............................................................88
GUIDELINEIMPLEMENTATIONSTRATEGIES............88
ECONOMICVALUEOFINTERVENTIONSAND
GUIDELINEIMPLEMENTATIONINASTHMA...........89
v
METHODOLOGY AND SUMMARY OF NEW
RECOMMENDATIONS GLOBAL STRATEGY FOR
ASTHMA MANAGEMENT AND PREVENTION: 2009
UPDATE* !
E
C
WhentheGlobalInitiativeforAsthma(GINA)programwas discusseachpublicationthatwasfeltwould haUvean
initiatedin1993,theprimarygoalwastoproduce impactonasthmamanagementandpreventiDonbyatleast
recommendationsforasthmamanagementbasedonthe 1memberoftheCommittee,andtoreachOaconsensuson
bestscientificinformationavailable.Itsfirstreport, thechangesinthereport. IntheabsenRceofconsensus
NHLBI/WHOWorkshopReport:GlobalStrategyfor disagreementsweredecidedbyanPopenvoteofthefull
AsthmaManagementandPreventionwasissuedin1995 committee. E
andrevisedin2002and2006. Thesereports,andtheir R
companiondocuments,havebeenwidelydistributedand SummaryofRecommendationsinthe2009Update:

R
translatedintomanylanguages.The2006reportwas BetweenJuly1,2008andJune30,2009,392articlesmet
basedonresearchpublishedthroughJune,2006andcan thesearchcriteria;10adOditionalpublicationswerebrought
befoundontheGINAwebsite(www.ginasthma.org). totheattentionofthe committee.Ofthe402articles, 23
R
paperswereidentifiedashavinganimpactontheGINA
E
The GINAScienceCommittee wasestablishedin2002to Report(updated2009)thatwaspostedonthewebsitein
T
reviewpublishedresearchonasthmamanagementand December2009eitherby:1)confirming,thatis,addingto
L
prevention,toevaluatetheimpactofthisresearchon orreplacinAganexistingreference,or2)modifying,thatis,
recommendationsintheGINAdocumentsrelatedto changin gthetextorintroducingaconceptrequiringanew
T
managementandprevention,andtopostyearlyupdates recommendationtothereport. Thesummaryisreported
O
ontheGINAwebsite.Thefirstupdateofthe2006report inthreesegments: A) Modificationsinthetext;B)
N
(2007update)includedtheimpactofpublicationsfrom Referencesthatprovidedconfirmationoranupdateof

July1,2006throughJune30,2007;the2008updated O previousrecommendations;andC)Changesor
includedtheimpactofpublicationsfromJuly1,2007 D modificationstothetext.
throughJune30,2008. This2009updateincludesthe
-
impactofpublicationsfromJuly1,2008throughJune 30, AsthmainChildren5YearsandYounger: In2008,a
L
2009. numberof pediatricexpertsdevelopedareportwhich
A
focusedonasthmacareinchildren5yearsandyounger.
I
Methods:ThemethodologyusedtoproducethRis2009 TheGlobalStrategyforAsthmaManagementand
updateincludedaPubMedsearchusingseEarchfields PreventioninChildren5YearsandYoungerwasreleased
establishedbytheCommittee:1)asthmaT,AllFields,All inearly2009(canbefoundonwww.ginasthma.org).
A
ages,onlyitemswithabstracts,ClinicalTrial,Human, Accordingly,theExecutiveSummary“ManagingAsthmain
M
sortedbyAuthors;and2)asthmaANDsystematic,All Children5YearsandYounger”thatappearedonpages
fields,ALLages,onlyitemswith abstracts,Human,sorted xiv–xviiisdeleted–seesection C.
D
byauthor. Inaddition,publicationsinpeerreviewjournals
E
notcapturedbyPubMedcouldbesubmittedtoindividual AsthmaControl: Inreviewofthepublishedliterature,the
T
membersoftheCommitteeprovidinganabstractandthe Committeedeterminedthatmanychangeswererequired
H
fullpaperweresubmittedin(ortranslatedinto)English. inthesegment“ClassificationofAsthma.” Accordingly,a
G
newsegmentappearsbeginningonpage22–seesection
I
AllmembersofthReCommitteereceivedasummaryof D.1).
citationsandaYllabstracts. Eachabstractwasassignedto
atleasttwoPCommitteemembers,althoughallmembers EvidenceReviews: InthepreparationofGINAreports,
wereoffeOredtheopportunitytoprovideanopiniononany includingthis2009update,levelsofevidencehasbeen
abstraCct. Membersevaluatedtheabstractor,uptoher/his completedusingfourcategoriesasdescribedonpagexiii.
judgment,thefullpublication,byansweringspecificwritten Thecommitteehashadextensivediscussionsinternally,
questionsfromashortquestionnaire,andtoindicateifthe aswellaswithproponentsofanewmethodologyfor
scientificdatapresentedimpactedonrecommendationsin describingrecommendations(theGRADEsystem).The
theGINAreport. Ifso,thememberwasaskedto implicationsforthewidespreadadaptationofthissystem
specificallyidentifymodificationsthatshouldbemade.The hasbeenexploredbytheCommitteewithregardto
entireGINAScienceCommitteemettwiceyearlyto resourceimplications,especiallygiventhealready
vi
*TheGlobalStrategyforAsthmaManagementandPrevention(updated2009),theupdatedPocketGuidesandthecompletelistofreferencesexaminedbytheCommitteeare
availableontheGINAwebsitewww.ginasthma.org.
†Members(2008-2009): M.FitzGerald,Chair;P.Barnes, N.Barnes,E.Bateman,A.Becker,J.Drazen,R.Lemanske,P.OBʼ yrne,K.Ohta,S.Pedersen,E.Pizzichini,H.
Reddel,S.Sullivan,S.Wenzel,H.Zar.
rigorousmethodofreviewingtheliteratureandupdating AS,BuistAS,etal. Asthmadruguseandthe
recommendationsthatiscurrentlyinplace. The developmentofChurg-Strausssyndrome(CSS).
committeehasdecidedthatitwouldbeinappropriateto PharmcoepidemiologyandDrugSafety. 2007;16:620-26.
implementthismethodologyforalltherecommendations
withinGINAandrecommendedinsteadtousethemethod- Pg31,leftcolumn,paragraph1,insert: …doesnot
ology,selectively,especiallywherethebalancebetween increasetheriskofasthma-relatedhospitalizations214…
!
efficacyandcosteffectivenessisunclearorwherethereis Reference214. JaeschkeR,O'ByrnePM,MejzaF,ENair
controversywithregardtotherecommendation. The P,LesniakW,BrozekJ,ThabaneL,ChengJ, C
CommitteeappliedGRADEtotwoquestions(seesection SchünemannHJ,SearsMR,GuyattG. ThesaUfetyoflong-
D.2)andwillcontinuetoexploretheuseofGRADE-like actingbeta-agonistsamongpatientswithastDhmausing
methodologyforissuesthatrequiremorein-depth inhaledcorticosteroids:systematicreviewand
O
evaluation. metaanalysis. AmJRespirCritCareMed.2008Nov
R
15;178(10):1009-16.Epub2008Sep5.
P
A. Modificationsinthetext:
E
Pg34,leftcolumn,endofparagraph1,insert: Dataona
R
Pg19,rightcolumn,insertendoffirstparagraph: although humanmonoclonalantibodyagainsttumornecrosisfactor

ithasbeenshownthattheuseofFeNoasameasureof (TNF)-alphasuggestthatthReriskbenefitequationdoes
asthmacontroldoesnotimprovecontrolorenable notfavortheuseofthisOclassoftreatmentsinsevere
reductionindoseofinhaledglucocorticosteroid55. asthma216. Referenc e216. WenzelSE,BarnesPJ,
R
Reference55. SzeflerSJ,MitchellH,SorknessCA, BleeckerER,BousquetJ,BusseW,DahlénSE,etal;T03
E
GergenPJ,O'ConnorGT,MorganWJ,etal. Management AsthmaInvestigators. Arandomized,double-blind,
T
ofasthmabasedonexhalednitricoxideinadditionto placebo-controlledstudyoftumornecrosisfactor-alpha
L
guideline-basedtreatmentforinner-cityadolescentsand blockadeinseverepersistentasthma. AmJRespirCrit
A
youngadults:arandomisedcontrolledtrial. Lancet.2008 CareMed.2009Apr1;179(7):549-58.Epub2009Jan8.

Sep20;372(9643):1065-72. T
O
Pg35,rightcolumn,beginningofparagraph4,insert:
Pg30,leftcolumn,line6,insert: althoughthereappearto DNietarysupplements,includingseleniumtherapy197 arenot
bedifferencesinresponseaccordingto ofprovenbenefitandtheuseofalowsodiumdietasan
O
symptom/inflammationphenotype212. Reference212. adjunctivetherapytonormaltreatmenthasnoadditional
D
HaldarP,PavordID,ShawDE,BerryMA,ThomasM, therapeuticbenefitinadultswithasthma. Inadditionithas

BrightlingCE,WardlawAJ,GreenRH. Clusteranalys-is noeffectonbronchialreactivitytomethacholine217.

andclinicalasthmaphenotypes. AmJRespirCritCLare Reference217. PogsonZE,AntoniakMD,PaceySJ,
A
Med.2008Aug1;178(3):218-24.Epub2008May14 LewisSA,BrittonJR,FogartyAW. Doesalowsodium
I
R dietimproveasthmacontrol?Arandomizedcontrolledtrial.
Pg30,leftcolumn,line11fromend,insert:EAmeta- AmJRespirCritCareMed.2008Jul15;178(2):132-8.
analysisofcase-controlstudiesofnon-veTrtebralfractures Epub2008May1.
inadultsusinginhaledglucocorticosterAoids(BDPor
equivalent)indicatedthatinolderadMults,therelativeriskof Pg38,Figure3.6,deletelaststatementandinsert:
non-vertebralfracturesincreases byabout12%foreach Inhaledglucocorticosteroidusehasthepotentialfor
D
1000µg/dayincreaseinthedoseBDPorequivalentbut reducingbonemineralaccretioninmalechildren
E
thatthemagnitudeofthisriskwasconsiderablylessthan progressingthroughpuberty,butthisriskislikelytobeout-
T
othercommonriskfactorsforfractureintheolder weighedbytheabilitytoreducetheamountoforal
H
adult213. Reference213. WeatherallM,JamesK,Clay corticosteroidsusedinthesechildren218. Reference218.
G
J,PerrinK,MasoliM,WijesingheM,BeasleyR. Dose- KellyHW,VanNattaML,CovarRA,TonasciaJ,Green
responserelationRsIhipforriskofnon-vertebralfracturewith RP,StrunkRC;CAMPResearchGroup. Effectoflong-
inhaledcorticoYsteroids. ClinExpAllergy.2008 termcorticosteroiduseonbonemineraldensityin
Sep;38(9):1P451-8.Epub2008Jun3. children:aprospectivelongitudinalassessmentinthe
O childhoodAsthmaManagementProgram(CAMP)study.
Pg30,rightcolumn,lastparagraphdeletelastsentence Pediatrics.2008Jul;122(1):e53-61.
C
andreferences52-54andreplacewith: Noassociation
wasfoundbetweenChurg-Strausssyndromeand Pg39,leftcolumn,endoffirstparagraph,insert:
leukotrienemodifiers,aftercontrollingforasthmadruguse, Montelukasthasnotbeendemonstratedtobeaneffective
althoughitisnotpossibletoruleoutmodestassociations inhaledglucocorticosteroidsparingalternativeinchildren
giventhatChurg-Strausssyndromeissorareandso withmoderate-to-severepersistentasthma219. Reference
highlycorrelatedwithasthmaseverity52. NewReference 219. StrunkRC,BacharierLB,PhillipsBR,SzeflerSJ,
52. HarroldLR,PattersonK,AndradeSE,DubeT,Go ZeigerRS,ChinchilliVM,etal.;CARENetwork.
vii
Azithromycinormontelukastasinhaledcorticosteroid- blockers,within24hoursof hospitaladmission,foran
sparingagentsinmoderate-to-severechildhoodasthma acutecoronaryevent,havelowerin-hospitalmortality
study. JAllergyClinImmunol.2008Dec;122(6):1138- rates366,367. Reference366. BabuKS,GadzikF,Holgate
1144.e4.Epub2008Oct25. ST. Absenceofrespiratoryeffectswithivabradinein
patientswithasthma. BrJClinPharmacol.2008
Pg51,rightcolumn,endoflastparagraph,insert: Lay Jul;66(1):96-101.Epub2008Mar13. Reference367.
!
educatorscanberecruitedandtrainedtodeliveradiscrete OlenchockBA,FonarowGG,PanW,HernandezA,E
areaofrespiratorycare(forexample,asthmaself- CannonCP;GetWithTheGuidelinesSteeringCoCmmittee.
managementeducation)withcomparableoutcomesto CurrentuseofbetablockersinpatientswithreaUctive
thoseachievedbyprimarycarebasedpracticenurses362 airwaydiseasewhoarehospitalizedwithacuDtecoronary
(EvidenceB). syndromes.AmJCardiol.2009Feb1;103(3):295-300.
O
Reference362. PartridgeMR,CaressAL,BrownC, Epub2008Nov19.
R
HenningsJ,LukerK,WoodcockA,CampbellM. Canlay
P
peopledeliverasthmaself-managementeducationas Pg62,leftcolumn,lastparagraph,deletesentenceand
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effectivelyasprimarycarebasedpracticenurses? replacewith: However,thisismorelikelytoleadtolossof
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Thorax.2008Sep;63(9):778-83.Epub2008Feb15.) asthmacontrol137,368(EvidenceB). Reference368:

GodardP,GreillierP,PigeRariasB,NachbaurG,
Pg52,rightcolumn,lastparagraph,deletefirstsentence DesfougeresJL,AttaliVO.Maintainingasthmacontrolin
andreplacewith:Althoughinterventionsforenhancing persistentasthma:co mparisonofthreestrategiesina6-
R
medicationadherencehavebeendeveloped363,studiesof monthdouble-blindrandomisedstudy.RespirMed.2008
E
adultsandchildrenwithasthma34haveshownthataround Aug;102(8):1124-31.Epub2008Jul7.
T
50%ofthoseonlong-termtherapyfailtotakemedications
L
asdirectedatleastpartofthetime. Reference363. Pg72,leftcolumn,endofthirdparagraph,insert: Adults
A
HaynesRB,AcklooE,SahotaN,McDonaldHP,YaoX. withasthmamaybeatincreasedriskofserious

Interventionsforenhancingmedicationadherence. pneumTococcaldisease370. Reference370. JuhnYJ,Kita
O
CochraneDatabaseSystRev. 2008Apr16;(2):CD000011 H,YawnBP,BoyceTG,YooKH,McGreeME,WeaverAL,
WNollanP,JacobsonRM. Increasedriskofserious
Pg55,leftcolumn,endoffirstparagraph,insert: Patients pneumococcaldiseaseinpatientswithasthma. JAllergy
O
withwell-controlledasthmaarelesslikelytoexperience ClinImmunol.2008Oct;122(4):719-23.Epub2008Sep
D
exacerbationsthanthosewhoseasthmaisnotwell- 13.

controlled364. -

Reference364: BatemanED,BousquetJ,BusseWLW, Pg89,rightcolumn,firstparagraph,insert: Useof
A
ClarkTJ,GulN,GibbsM,PedersenS;GOALSteering administrativedatasets(e.g.,dispensingrecords)orurgent
I
CommitteeandInvestigators. StabilityofasthRmacontrol healthcareutilizationcanhelptoidentifyat-riskpatientsor
withregulartreatment:ananalysisoftheGaEiningOptimal toauditthequalityofhealthcare23. Reference23.
AsthmacontroL(GOAL)study. Allergy.2T008 BereznickiBJ,PetersonGM,JacksonSL,WaltersEH,
Jul;63(7):932-8. A FitzmauriceKD,GeePR. Data-miningofmedication
M recordstoimproveasthmamanagement. MedJAust.
Pg56,leftcolumn,endofthirdp aragraphdeleteas 2008Jul7;189(1):21-5.
D
indicatedandinsert:Installationofnon-polluting,more
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effectiveheating(heatpump,woodpelletburner,flued B. Referencesthatprovidedconfirmationorupdateof
T
gas)inthehomesofchildrenwithasthmadoesnot previousrecommendations:
H
significantlyimprovelungfunctionbutdoessignificantly
G
reducesymptomsofasthma,daysoffschool,healthcare Pg24: Rightcolumn,replacereference32.HorvathI,
utilization,andviRsIitstoapharmacist365. HuntJ,BarnesPJ,AlvingK,AntczakA,BaraldiE,etal.
Reference36Y5. Howden-ChapmanP,PierseN,Nicholls Exhaledbreathcondensate:methodological
S,GillespieP-BennettJ,ViggersH,CunninghamM,etal. recommendationsandunresolvedquestions.EurRespirJ
EffectsoOfimprovedhomeheatingonasthmaincommunity 2005;26:523-48.
dwellingchildren: randomizedcontrolledtrial. BMJ.2008
C
Sep23;337:a1411.doi:10.1136/bmj.a1411. Pg30: Leftcolumn,insertreference211. O'ByrnePM,
NayaIP,KallenA,PostmaDS,BarnesPJ. Increasing
Pg57,leftcolumn,endoffirstparagraph,insert: Beta dosesofinhaledcorticosteroidscomparedtoaddinglong-
blockershaveaprovenbenefitinthemanagementof actinginhaledbeta2-agonistsinachievingasthmacontrol.
patientswithacutecoronarysyndromesandforsecondary Chest.2008Dec;134(6):1192-9.Epub2008Aug8.
preventionofcoronaryevents. Datasuggestthatpatients
withasthmawhoreceivenewermorecardio-selectivebeta
viii