Gina older-Gina Sylvestre | Geography | The University of Winnipeg

Teaching Areas: Housing, well-being and residential migration Environmental impacts on mobility of vulnerable populations Social exclusion and aging Community development and intergenerational linkages. Research Interests: Transitions in transportation usage by older adults Winter sidewalk condition bulletin Neighbourhood deprivation and aging Leadership development and knowledge mobilization of rural seniors. Publications: Sylvestre, G. Aging and sustainability: Creating a discourse on places of inclusive mobility for the promotion of longevity. In ed.

Gina older

Gina older

Safety of regular olderr or salmeterol in adults with asthma: an overview of Cochrane reviews. Gina older for change For clinical utility, advice about primary prevention of asthma has been opder from information about secondary prevention of symptoms in patients with an existing diagnosis of asthma. The Sheriff Dummy strap hinge Mr. Evaluation of SaO 2 as a predictor of outcome in Gina older presenting with acute asthma. Global strategy for the diagnosis and management of asthma in children 5 years and younger. How to ask patients about their medication adherence.

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However, uptake of existing guidelines is poor. A major revision of the GINA report was published in , and updated in , reflecting an evolving understanding of heterogeneous airways disease, a broader evidence base, increasing interest in targeted treatment, and evidence about effective implementation approaches.

During development of the report, the clinical utility of recommendations and strategies for their practical implementation were considered in parallel with the scientific evidence. This article provides a summary of key changes in the GINA report, and their rationale.

The impact of asthma is felt not only by patients, but also by families, healthcare systems and society. Asthma is one of the most common chronic diseases affecting children and young adults, and there is increasing recognition of its impact upon working-age adults, the importance of adult-onset asthma, and the contribution of undiagnosed asthma to respiratory symptoms and activity limitation in the elderly.

The Global Initiative for Asthma GINA was established in in collaboration with the National Heart, Lung and Blood Institute and the World Health Organization, under the leadership of Drs Suzanne Hurd and Claude Lenfant, with the goals of disseminating information about asthma management, and providing a mechanism to translate scientific evidence into improved asthma care.

Substantial advances have been made in scientific knowledge about the nature of asthma, a wide range of new medications, and understanding of important emotional, behavioural, social and administrative aspects of asthma care.

However, in spite of these efforts, and the availability of highly effective therapies, international surveys provide ongoing evidence of suboptimal asthma control [ 6 — 8 ] and poor adherence to existing guidelines [ 9 — 11 ]. New approaches are needed. Since the last major revision of the GINA report in [ 12 ], there has been a transition in understanding of asthma and chronic obstructive pulmonary disease COPD as heterogeneous and sometimes overlapping conditions, awareness of the contribution of common problems such as adherence, inhaler technique and health literacy to poorly controlled asthma, an expanding research evidence base that incorporates highly controlled efficacy studies, pragmatic studies and observational data in broad populations [ 13 ], increasing interest in individualised healthcare, and growing attention to effective strategies for changing health-related behaviour.

This context is reflected in key changes in evidence, recommendations and format in the major revision of the GINA strategy report that was published in May , and further updated in April The aim of this article is to summarise the key changes in the GINA strategy report, with a description of the rationale for each change and a sample of clinical tools from the full report.

More detail about clinical recommendations and supporting evidence, and the full range of clinical tools, are available in the latest update of the full GINA report published in April , which is available from the GINA website www.

An over-arching aim was to substantially restructure the report in order to facilitate its implementation in clinical practice, while maintaining the existing strong evidence base. Recognising that key images and tables in the report would have the greatest impact, we began by soliciting broad input on three areas: the definition of asthma, assessment of asthma control, and control-based management. Members of the multinational GINA Assembly, primary care clinicians, respiratory specialists and other expert advisers were asked to provide feedback about existing GINA materials on these topics, with regard to their evidence, clarity and feasibility for implementation in clinical practice, and to identify other sections in need of substantial revision.

Over 50 responses were received. Importantly, the clinical relevance of recommendations, and strategies for their implementation, were considered in parallel with the review of scientific evidence. The final draft of the report was extensively peer-reviewed, with strongly supportive feedback received from over 40 reviewers including seven external reviewers.

The report was published on World Asthma Day in May , with an update of new evidence in April Providing a summary of evidence about asthma care is not sufficient to change outcomes; there is now a strong evidence base about effective and ineffective methods for implementing clinical guidelines and achieving behaviour change by health professionals and patients [ 14 ]. Evidence-based recommendations need to be presented in a way that is both accessible and relevant to clinicians, and integrated into strategies that are feasible for health professionals to use in their busy clinical practice.

The GINA report, therefore, now focuses not only on the existing strong evidence base about what treatment should be recommended, but also on clarity of language and on inclusion of clinical tools evidence-based where possible for how this can be done in clinical practice.

Recommendations are now presented in a user-friendly way, with clear language and extensive use of summary tables, clinical tools and flow-charts.

The electronic report includes hyperlinked cross-references for figures, tables and citations. The main report includes the rationale and evidence levels for key recommendations, with more detailed supporting material and information about epidemiology, pathogenesis and mechanisms moved to an online appendix. The result is a report that is less like a textbook, and more like a practical manual, that can be adapted to local social, ethnic, health system and regulatory conditions for national guidelines.

Additional resources including pocket guides and slide kits are also available on the GINA website www. Advice about confirming asthma diagnosis in patients already on treatment, and in special populations, including pregnant women and the elderly.

Improving the diagnosis of asthma is the first step to improving outcomes. At a global level asthma is both under- [ 2 ] and over-diagnosed [ 15 — 18 ], with under-diagnosis contributing to unnecessary burden for patients and families and increased costs for the health system, and over-diagnosis increasing treatment costs and exposing patients to unnecessary risk of side-effects.

A key priority for GINA was that the new definition should be feasible for use in diagnosing asthma in clinical practice, while also reflecting the complexity of asthma as a heterogeneous disease; the definition also needed to display flexibility within the context of rapidly emerging evidence that different mechanisms underlie the cardinal clinical features of variable respiratory symptoms and variable expiratory airflow limitation by which asthma is defined.

The new definition of asthma. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation. By contrast with anaemia, arthritis and cancer, evidence about the underlying mechanisms in asthma is much less well-established, with most existing evidence coming from patients with long-standing and clinically severe asthma; further research in broader populations is needed.

The rationale is that, although chronic airway inflammation is characteristic of most currently known asthma phenotypes, the absence of inflammatory markers should not preclude the diagnosis of asthma being made in patients with variable expiratory airflow limitation and variable respiratory symptoms. This should not be taken to suggest a lesser emphasis on anti-inflammatory treatment; on the contrary, as described below, indications for inhaled corticosteroid ICS treatment have been expanded.

Importantly, the definition also avoids past assumptions about the relationship between airway inflammation, airway hyperresponsiveness, symptoms and exacerbations, and the inclusion of heterogeneity in the definition reinforces the need for ongoing research to identify specific treatment targets [ 20 ]. Practical tools for diagnosis of asthma. The key changes in this section are consequent upon the new definition of asthma, and are aimed at reducing both under- and over-diagnosis.

There is an emphasis on making a diagnosis in patients presenting with respiratory symptoms, preferably before commencing treatment, and on documenting the basis of the diagnosis in the patient's medical records. The chapter includes a table of specific criteria for documenting variable expiratory airflow limitation, a key component of asthma diagnosis, for use in clinical practice or clinical research.

A list of common asthma phenotypes is provided, to prompt clinicians, including those in primary care, to recognise different clinical patterns among their patients, even if they lack access to complex investigations. Confirming the diagnosis of asthma in patients already on treatment.

Different approaches are suggested for confirming the diagnosis in patients already on treatment, depending on their clinical status. Advice is provided about how to step down treatment if needed for diagnostic confirmation, based on available evidence and practical considerations, such as ensuring the patient has a written asthma action plan, and choosing a suitable time no respiratory infection, not travelling, not pregnant.

Diagnosis of asthma in special populations e. These sections are consistent with the emphasis in GINA on tailoring asthma management for different populations. Clinical algorithm for distinguishing between uncontrolled and severe refractory asthma.

The significance of this change was not necessarily obvious, since in typical allergic asthma and with a conventional ICS-based treatment model, short-term improvement in symptoms is often paralleled by longer-term reduction in exacerbations. However, in different asthma phenotypes or with different treatments, discordance may be seen between symptoms and risks.

Discordance in treatment response between symptoms and risk can be biologically informative about the underlying mechanism [ 27 ]. Asthma control is assessed from two domains: symptom control and risk factors. The template for assessing asthma control now includes an expanded list of modifiable and non-modifiable factors that are predictors of risk for future adverse outcomes, independent of asthma symptoms.

Given the diverse mechanisms underpinning these various risks, and that not all risk factors require a step-up in asthma treatment, symptoms and risk factors were not combined arithmetically or in a grid. Lung function and symptoms should be considered separately. In the GINA assessment of asthma control, lung function is no longer numerically combined with symptoms, as low or high symptoms can outweigh a discordant signal from lung function [ 24 ], instead of prompting a different response.

For example, if symptoms are frequent and lung function normal, alternative or comorbid causes such as vocal cord dysfunction should be considered; if symptoms are few but lung function is low, poor perception of airflow limitation or a sedentary lifestyle should be considered. Peak expiratory flow PEF monitoring may be used short-term in the diagnosis of asthma, including work-related asthma [ 31 ], and in assessing triggers, flare-ups and response to treatment.

Long-term PEF monitoring is largely reserved for patients with more severe asthma, those with impaired perception of airflow limitation, and other specific clinical circumstances.

When PEF is used, data should be displayed on a standardised chart with low aspect ratio to avoid misinterpretation [ 32 ]. Asthma severity is a retrospective label , assessed after a patient has been on treatment for at least several months [ 21 ]. A clinical algorithm for distinguishing between uncontrolled asthma and severe refractory asthma. Specialist protocols for identifying severe refractory asthma often start with confirmation of the diagnosis of asthma [ 34 ].

This is an efficient approach, as these problems are often readily identifiable, can be corrected in primary care [ 37 ], and, if improved inhaler technique and adherence lead to substantial improvements in symptoms and lung function, may avoid the need for additional investigations or specialist referral to confirm the diagnosis of asthma. This figure highlights key priorities in management of asthma in the GINA global asthma strategy.

ICS: inhaled corticosteroids. Figure modified with permission of GINA. In clinical practice, a common response to uncontrolled asthma is to step up treatment, with an attendant increase in healthcare costs and risk of side-effects; yet, as highlighted in the previous section, there are many modifiable contributors to both uncontrolled symptoms and exacerbations. While avoidance strategies are essential in some contexts, such as occupational asthma or confirmed food allergy, broad avoidance recommendations may lead to the perception that all patients should avoid anything that provokes their asthma symptoms.

During the review process, many contributors also requested advice about how to implement treatment recommendations in clinical practice. Control-based care. Figure 1 summarises key concepts in the GINA cycle of asthma care.

Alternative strategies for adjusting treatment are briefly described, including sputum-guided treatment, which is currently recommended for patients in centres that have routine access to this tool; the benefits are primarily seen in patients with more severe asthma requiring secondary care.

An explicit framework for tailoring treatment. The GINA report now draws a clear distinction between population-level e. The former are generally based on group mean data for symptoms, lung function and exacerbations, as well as safety, availability and overall cost.

The extent to which treatment can be tailored depends on local regulations and access, and is limited at present by lack of long-term evidence in broad populations. Expansion of the indication for low dose ICS. By contrast, there is a lack of evidence for safety of treating asthma with SABA alone.

GINA now recommends that treatment with SABA alone should be reserved for patients with asthma symptoms less than twice per month, no waking due to asthma in the past month, and no risk factors for exacerbations, including no severe exacerbations in the previous year. ICS treatment is recommended once symptoms exceed this level, not necessarily to reduce the likely low burden of symptoms, but to reduce the risk of severe exacerbations.

Further studies are needed, including rigorous cost-effectiveness analyses based on current pricing structures. Before considering any step-up, check diagnosis, inhaler technique, and adherence. Although most guidelines mention inhaler technique and adherence, general awareness of their importance remains low and clinical skills in their assessment poor [ 46 ]; optimisation of use of current medications is rarely included in the design of randomised controlled trials that involve stepping up for uncontrolled asthma.

In GINA, every recommendation about treatment adjustment now includes a reminder to first check inhaler technique and adherence and to confirm that the symptoms are due to asthma.

Special populations and clinical contexts. The emphasis on tailoring treatment includes a summary of management in special contexts surgery, exercise-induced bronchoconstriction ; for patients with comorbidities e. Strategies to reduce the impact of impaired health literacy. In addition to long-standing recommendations promoting a partnership between the patient and the healthcare provider, the importance of impaired health literacy is now also emphasised, and practical evidence-based strategies [ 49 ] to help reduce its impact are provided.

Examples include prioritising information from most to least important, and asking a second person nurse, family member to repeat key messages. A new stepwise treatment graphic to emphasise key messages. Step 2 treatment now comprises a larger component of the figure, to emphasise that most patients with asthma should be treated with, and are likely to respond to, low-dose ICS.

The two options for reliever medication are shown, i. Key clinical messages are included beneath the stepwise figure, to ensure that it is complete in itself if the figure is viewed in isolation from the surrounding text. A table of specific step-down options. Step-down options based on the patient's current treatment are listed, with related evidence levels. Treatment of modifiable risk factors.

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Gina older

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