Post on 12-Apr-2017
Guías GINA y PRACTALL
Residente: Dr. Mauricio Gerardo Ochoa Montemayor
Asesor: Dra. Alejandra Macías Weinmann
Definición, descripción y
diagnóstico
Dr. Ochoa
CRAIC Mty
Introducción
El asma es un problema de salud global que afecta todos
los grupos de edades, con prevalencia en aumento,
especialmente en niños.
En 1993 el National Heart, Lung and Blood Institute en
colaboración con la Organización Mundial de la Salud
creó el informe ‘Estrategia Global para el Tratamiento y la
Prevención del Asma´.
Tras ello se formó la Iniciativa Global para el Asma
(GINA)
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Definición
El asma es una enfermedad heterogénea, caracterizada
por una inflamación crónica de las vías aéreas.
Se define por síntomas respiratorios como sibilancias,
dificultad respiratoria, opresión torácica y tos, con una
limitación variable del flujo aéreo espiratorio.
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Descripción del asma
Es una enfermedad crónica común que afecta 1-18% de la
población
Síntomas variables de disnea, sibilancias, opresión torácica
y tos con limitación variable del flujo aéreo espiratorio
Desencadenada por factores como ejercicio, alérgenos,
infecciones, etc.
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Criterios diagnósticos
Antecedentes de sibilancias, opresión torácica, tos, disnea
Más de un síntoma respiratorio
Ocurren con tiempo e intensidad variable
Empeoran en la noche o al despertar
Desencadenadas por ejercicio, risa, alérgenos, frío
Empeoran con infecciones
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Criterios diagnósticos
Reversibilidad con broncodilatador
Exceso de variabilidad 2 veces al vía por dos semanas
>10% en adultos, >13% en niños
Mejoría en función pulmonar después de 4 semanas de
antiinflamatorio
Prueba de esfuerzo positiva
Prueba de reto bronquial positiva
Exceso de variación entre función pulmonar entre
consultas
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Diagnóstico
Antecedentes personales y familiares
Exploración física
Pruebas de función pulmonar para documentar
variabilidad en flujo espiratorio
Otras pruebas:
Test de provocación bronquial
Pruebas de alergia
FENO
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Diagnósticos diferenciales
Dr. Ochoa
CRAIC Mty
Diagnóstico en poblaciones especiales
Tos como único síntoma
Considerar:
Variante tos
IECA
ERGE
Sinusitis crónica
Disfunción de cuerdas vocales
Documentar variabilidad en función pulmonar
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Diagnóstico en poblaciones especiales
Asma ocupacional
Inducida o agravada por alérgenos
5-20% de asma de inicio en adultos
Interrogar síntomas fuera del trabajo
Atletas
Confirmar con pruebas de función pulmonar
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Diagnóstico en poblaciones especiales
Tercera edad
Pobre percepción de limitación del flujo aéreo
Disnea “normal”
Actividad física disminuida
Comorbilidades
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Patrones de sibilancias
Transitorias
No-atópicas
Asma persistente
Sibilancias intermitentes
graves
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al. Allergy. Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty
Factores determinantes
Factores genéticos
Ambiente y estilo de vida
Aeroalérgenos
Alergias alimentarias
Infección
Humo de tabaco
Contaminación
Nutrición
Ejercicio
Clima
EstrésDiagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al. Allergy. Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty
Elementos que definen fenotipo
Edad
Lactantes
Preescolares
Escolares
Adolescentes
Gravedad
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al. Allergy. Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty
Fisiopatología
Anomalías inmunológicas
Inmunidad de células T
Atopia
Remodelación de la vía aérea
Inflamación bronquial
Inflamación nasal
Epitelio
Células inflamatorias
Obstrucción de la vía aérea
HiperreactividadDiagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al. Allergy. Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty
Diagnóstico
Historia clínica
Frecuencia y gravedad de los síntomas
Patrón de los síntomas
Confirmación de sibilancias por el médico
Interrogar sobre
Tos, sibilancias
Relación causal
Patrón de sueño
Exacerbaciones
Síntomas nasales
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al. Allergy. Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty
Diagnóstico
Lactantes
Ruidos al respirar
Vómito asociado a la tos
Retracción
Dificultad para la alimentación
Cambios en la frecuencia respiratoria
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al. Allergy. Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty
Diagnóstico
Niños mayores de 2 años
Disnea
Fatiga
Malestar
Desempeño escolar
Desempeño en actividad física
Evita actividades
Relación causal
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al. Allergy. Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty
Evaluación del asma
Dr. Ochoa
CRAIC Mty
Evaluación del asma
Control: Grado en el cual las manifestaciones se observan
en el paciente o se reducen/desaparecen con el
tratamiento.
Tiene dos componentes
Control de los síntomas
Riesgo de resultados adversos
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Evaluación de control de los síntomas
Los síntomas varían en intensidad y frecuencia,
contribuyendo a la carga para el paciente.
El mal control se asocia fuertemente con un aumento en
el riesgo de exacerbaciones
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Herramientas para evaluar control del asma
Asthma Control Questionnaire (ACQ)
Valores de 0-6
0 – 0.75: bien controlada
>1.5: con pobre control
Asthma Control Test (ACT)
Valores de 5-25
20-25: bien controlada
16-19: parcialmente controlada
5-15: con pobre control
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
A. Symptom control
In the past 4 weeks, has the patient had:Well-
controlled
Partly
controlled
Uncontrolled
• Daytime asthma symptoms more
than twice a week? Yes No
None of
these
1-2 of
these
3-4 of
these
• Any night waking due to asthma? Yes No
• Reliever needed for symptoms*
more than twice a week? Yes No
• Any activity limitation due to asthma? Yes No
Dr. Ochoa
CRAIC Mty
Evaluar el riesgo a futuro
FEV1 disminuido
Identifica pacientes con mayor riesgo de exacerbaciones
(<60%)
Inflamación no tratada
FEV1 normal o aumentado
Considerar otras causas
Reversibilidad persistente
Mal control
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
© Global Initiative for Asthma
Assessment of risk factors for poor asthma
outcomes
GINA 2015, Box 2-2B (4/4)
Risk factors for exacerbations include:
• Ever intubated for asthma
• Uncontrolled asthma symptoms
• Having ≥1 exacerbation in last 12 months
• Low FEV1 (measure lung function at start of treatment, at 3-6 months
to assess personal best, and periodically thereafter)
• Incorrect inhaler technique and/or poor adherence
• Smoking
• Obesity, pregnancy, blood eosinophilia
Risk factors for fixed airflow limitation include:
• No ICS treatment, smoking, occupational exposure, mucus
hypersecretion, blood eosinophilia
Risk factors for medication side-effects include:
• Frequent oral steroids, high dose/potent ICS, P450 inhibitorsDr. Ochoa
CRAIC Mty
Gravedad del asma
Se evalúa de manera retrospectiva
Leve: paso 1, 2
Moderada: paso 3
Grave: paso 4 o 5
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Asma grave VS no controlada
Técnica de inhalador (80%)
Apego
Diagnóstico incorrecto
Comorbilidades
Exposición al medio ambiente
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Tratamiento para controlar
síntomas y disminuir riesgo
Dr. Ochoa
CRAIC Mty
Tratamiento
Metas
Alcanzar buen control de los síntomas y mantener un nivel
normal de actividades diarias
Disminuir el riesgo de exacerbaciones, limitación del flujo
aéreo, efectos adversos
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Ciclo de tratamiento
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function
Dr. Ochoa
CRAIC Mty
Tratamiento
Criterios para elección
Poblacionales
Paciente
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
*For children 6-11 years,
theophylline is not
recommended, and preferred
Step 3 is medium dose ICS
**For patients prescribed
BDP/formoterol or BUD/
formoterol maintenance and
reliever therapy
# Tiotropium by soft-mist
inhaler is indicated as add-on
treatment for adults
(≥18 yrs) with a history of
exacerbations
Diagnosis
Symptom control & risk factors(including lung function)
Inhaler technique & adherence
Patient preference
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function
Other
controller
options
RELIEVER
STEP 1 STEP 2STEP 3
STEP 4
STEP 5
Low dose ICS
Consider low
dose ICS
Leukotriene receptor antagonists (LTRA)
Low dose theophylline*
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
As-needed short-acting beta2-agonist (SABA) As-needed SABA or low dose ICS/formoterol**
Low dose
ICS/LABA*
Med/high
ICS/LABA
Refer for
add-on
treatment
e.g.
anti-IgE
PREFERRED CONTROLLER
CHOICE
Add tiotropium#High dose ICS + LTRA (or + theoph*)
Add tiotropium#Add low dose OCS
Dr. Ochoa
CRAIC Mty
Revisión y ajuste de tratamiento
Beneficio total a los 3-4 meses de tratamiento
Evaluar en cada visita, frecuencia según el paciente
Incremento
Sostenido (2-3 meses)
Corto plazo (1-2 semanas)
Día a día
Descenso
Se puede reducir al lograr control por 3 meses
Metas
Encontrar el tratamiento mínimo efectivo
Estimular al paciente para continuar un control regular
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Tratamiento no farmacológico
Cesar el tabaquismo
Actividad física
Control de medio ambiente
Uso de medicamentos
Dieta
Control de peso
Vacunación
Control de estrés
Inmunoterapia
Evitar alérgenos (intra/extramuros)
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Comorbilidades
Obesidad
ERGE
Ansiedad/depresión
Alergia alimentaria/anafilaxia
Rinitis, sinusitis y pólipos nasales
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Tratando poblaciones especiales
Adolescentes
Broncoconstricción inducida por el ejercicio
Atletas
Embarazo
Asma ocupacional
Tercera edad
Procedimientos quirúrgicos
Enfermedad respiratoria exacerbada por aspirina
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Diagnóstico de asma, EPOC y
ACOS
Dr. Ochoa
CRAIC Mty
Definiciones
EPOC: Enfermedad común prevenible y tratable
caracterizada por limitación del flujo aéreo persistente
progresivo asociado a respuestas inflamatorias crónicas
incrementadas por partículas o gases nocivos.
Asthma-COPD overlap syndrome (ACOS): Limitación del
flujo aéreo persistente con características asociadas a
asma y características asociadas a EPOC.
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Abordaje diagnóstico por pasos
Paso 1: ¿El paciente tiene enfermedad respiratoria
crónica?
Historia clínica
Exploración física
Radiografías
Cuestionarios
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Abordaje diagnóstico por pasos
Paso 2: Diagnóstico sindromático
Reunir características que apoyen diagnóstico de asma o EPOC
Comparar entre asma y EPOC
Considerar el nivel de certeza de diagnóstico de asma o
COPD
Paso 3: Espirometría
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
© Global Initiative for AsthmaGINA 2014 © Global Initiative for AsthmaGINA 2015, Box 5-4
SYNDROMIC DIAGNOSIS IN ADULTS(i) Assemble the features for asthma and for COPD that best describe the patient.
(ii) Compare number of features in favour of each diagnosis and select a diagnosis
STEP 2
Features: if present suggest - ASTHMA COPD
Age of onset Before age 20 years After age 40 years
Pattern of symptoms Variation over minutes, hours or days
Worse during the night or early morning
Triggered by exercise, emotions
including laughter, dust or exposure
to allergens
Persistent despite treatment
Good and bad days but always daily
symptoms and exertional dyspnea
Chronic cough & sputum preceded
onset of dyspnea, unrelated to triggers
Lung function Record of variable airflow limitation
(spirometry or peak flow)
Record of persistent airflow limitation
(FEV1/FVC < 0.7 post-BD)
Lung function between
symptoms Normal Abnormal
Past history or family history Previous doctor diagnosis of asthma
Family history of asthma, and other
allergic conditions (allergic rhinitis or
eczema)
Previous doctor diagnosis of COPD,
chronic bronchitis or emphysema
Heavy exposure to risk factor: tobacco
smoke, biomass fuels
Time course No worsening of symptoms over time.Variation in symptoms either seasonally, or from year to year
May improve spontaneously or have an immediate response to bronchodilators or to ICS over weeks
Symptoms slowly worsening over time(progressive course over years)
Rapid-acting bronchodilator treatmentprovides only limited relief
Chest X-ray Normal Severe hyperinflation
DIAGNOSIS
CONFIDENCE IN
DIAGNOSIS
Asthma
Asthma
Some features
of asthma
Asthma
Features of both
Could be ACOS
Some features
of COPD
Possibly COPD
COPD
COPD
NOTE: • These features best distinguish between asthma and COPD. • Several positive features (3 or more) for either asthma or COPD suggest
that diagnosis. • If there are a similar number for both asthma and COPD, consider diagnosis of ACOS
Dr. Ochoa
CRAIC Mty
© Global Initiative for Asthma
Step 3 - Spirometry
Spirometric variable Asthma COPD ACOS
Normal FEV1/FVC
pre- or post-BD
Compatible with asthma Not compatible with
diagnosis (GOLD)
Not compatible unless
other evidence of chronic
airflow limitation
FEV1 ≥80% predicted Compatible with asthma
(good control, or interval
between symptoms)
Compatible with GOLD
category A or B if post-
BD FEV1/FVC <0.7
Compatible with mild
ACOS
Post-BD increase in
FEV1 >12% and 400mL
from baseline
- High probability of
asthma
Unusual in COPD.
Consider ACOS
Compatible with
diagnosis of ACOS
Post-BD FEV1/FVC <0.7- Indicates airflow
limitation; may improve
Required for diagnosis
by GOLD criteria
Usual in ACOS
Post-BD increase in
FEV1 >12% and 200mL
from baseline (reversible
airflow limitation)
- Usual at some time in
course of asthma; not
always present
Common in COPD and
more likely when FEV1
is low
Common in ACOS, and
more likely when FEV1 is
low
FEV1<80% predicted Compatible with asthma.
A risk factor for
exacerbations
Indicates severity of
airflow limitation and risk
of exacerbations and
mortality
Indicates severity of
airflow limitation and risk
of exacerbations and
mortality
GINA 2015, Box 5-3
Dr. Ochoa
CRAIC Mty
Abordaje diagnóstico por pasos
Paso 4: Iniciar tratamiento
Si apoya asma como diagnóstico único
Iniciar tratamiento según estrategia de GINA
Si apoya EPOC como diagnóstico único
Iniciar tratamiento según reporte de GOLD
ACOS
Tratamiento para asma de manera inicial
Corticoesteroide inhalado a dosis bajas
Agregar LABA o LAMA
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Abordaje diagnóstico por pasos
Paso 5: Referir para investigaciones especializadas
Pacientes con síntomas persistentes a pesar del tratamiento
Incertidumbre diagnóstica
Sospecha de un diagnóstico pulmonar adicional
Enfermedad crónica con poca evidencia de asma o EPOC
Pacientes con comorbilidades
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Diagnóstico y tratamiento de asma
en niños de 5 años y menores
Dr. Ochoa
CRAIC Mty
Diagnóstico
Asma y sibilancias en niños
El asma es la enfermedad crónica de la infancia más común,
siendo la primera causa de morbilidad infantil.
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Diagnóstico
Inducida por virus
Sibilancias recurrentes en niños
Asociadas a IVRS (6-8/año)
Fenotipos de sibilancias
Basado en síntomas
Sibilancias episódicas o por múltiples desencadenantes
Basado en tiempo
Transitorios (inicio y fin antes de los 3 años), persistentes (antes de
los 3 hasta después de los 6) e inicio tardío (después de los 3)
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
© Global Initiative for Asthma
Features suggesting asthma in children ≤5 years
Feature Characteristics suggesting asthma
Cough Recurrent or persistent non-productive cough that may be worse at
night or accompanied by some wheezing and breathing difficulties.
Cough occurring with exercise, laughing, crying or exposure to
tobacco smoke in the absence of an apparent respiratory infection
Wheezing Recurrent wheezing, including during sleep or with triggers such as
activity, laughing, crying or exposure to tobacco smoke or air pollution
Difficult or heavy
breathing or
shortness of breath
Occurring with exercise, laughing, or crying
Reduced activity Not running, playing or laughing at the same intensity as other
children; tires earlier during walks (wants to be carried)
Past or family history Other allergic disease (atopic dermatitis or allergic rhinitis)
Asthma in first-degree relatives
Therapeutic trial with
low dose ICS and
as-needed SABA
Clinical improvement during 2–3 months of controller treatment and
worsening when treatment is stopped
GINA 2015, Box 6-2
Dr. Ochoa
CRAIC Mty
Pruebas adicionales
Prueba terapéutica
Pruebas de atopia
Radiografía de tórax
Pruebas de función pulmonar
FENO
Perfil de riesgo (API)
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Diagnósticos diferenciales
Buscar otro diagnóstico en caso de encontrar:
Falla en el crecimiento
Inicio muy temprano de los síntomas
Vómito y síntomas respiratorios
Sibilancias continuas
Respuesta nula al tratamiento
Sin asociación a desencadenantes (IVRS)
Signos focales pulmonares o cardiovasculares
Hipoxemia fuera de infecciones virales
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
© Global Initiative for Asthma
Features suggesting asthma in children ≤5 years
Feature Characteristics suggesting asthma
Cough Recurrent or persistent non-productive cough that may be worse at
night or accompanied by some wheezing and breathing difficulties.
Cough occurring with exercise, laughing, crying or exposure to
tobacco smoke in the absence of an apparent respiratory infection
Wheezing Recurrent wheezing, including during sleep or with triggers such as
activity, laughing, crying or exposure to tobacco smoke or air pollution
Difficult or heavy
breathing or
shortness of breath
Occurring with exercise, laughing, or crying
Reduced activity Not running, playing or laughing at the same intensity as other
children; tires earlier during walks (wants to be carried)
Past or family history Other allergic disease (atopic dermatitis or allergic rhinitis)
Asthma in first-degree relatives
Therapeutic trial with
low dose ICS and
as-needed SABA
Clinical improvement during 2–3 months of controller treatment and
worsening when treatment is stopped
GINA 2015, Box 6-2
Dr. Ochoa
CRAIC Mty
© Global Initiative for Asthma
Common differential diagnoses of asthma in
children ≤5 years
Condition Typical features
Recurrent viral respiratory
infections
Mainly cough, runny congested nose for <10 days; wheeze
usually mild; no symptoms between infections
Gastroesophageal reflux Cough when feeding; recurrent chest infections; vomits easily
especially after large feeds; poor response to asthma
medications
Foreign body aspiration Episode of abrupt severe cough and/or stridor during eating or
play; recurrent chest infections and cough; focal lung signs
Tracheomalacia or
bronchomalacia
Noisy breathing when crying or eating, or during URTIs; harsh
cough; inspiratory or expiratory retraction; symptoms often
present since birth; poor response to asthma treatment
Tuberculosis Persistent noisy respirations and cough; fever unresponsive to
normal antibiotics; enlarged lymph nodes; poor response to BD
or ICS; contact with someone with TB
Congenital heart disease Cardiac murmur; cyanosis when eating; failure to thrive;
tachycardia; tachypnea or hepatomegaly; poor response to
asthma medications
GINA 2015, Box 6-3 (1/2)
Dr. Ochoa
CRAIC Mty
Tratamiento
Infrequent
viral wheezing
and no or
few interval
symptoms
Symptom pattern consistent with asthma
and asthma symptoms not well-controlled, or
≥3 exacerbations per year
Symptom pattern not consistent with asthma but
wheezing episodes occur frequently, e.g. every
6–8 weeks.
Give diagnostic trial for 3 months.
Asthma diagnosis, and
not well-controlled on
low dose ICS
Not well-
controlled
on double
ICS
First check diagnosis, inhaler skills,
adherence, exposures
CONSIDER
THIS STEP FOR
CHILDREN WITH:
RELIEVER
Other
controller
options
PREFERRED
CONTROLLER
CHOICE
As-needed short-acting beta2-agonist (all children)
Leukotriene receptor antagonist (LTRA)
Intermittent ICS
Low dose ICS + LTRA Add LTRA
Inc. ICS
frequency
Add intermitt ICS
Daily low dose ICS
Double
‘low dose’
ICS
Continue
controller
& refer for
specialist
assessment
STEP 1 STEP 2STEP 3
STEP 4
Dr. Ochoa
CRAIC Mty
Dosis de corticosteroides inhalados
Inhaled corticosteroid Low daily dose (mcg)
Beclometasone dipropionate (HFA) 100
Budesonide (pMDI + spacer) 200
Budesonide (nebulizer) 500
Fluticasone propionate (HFA) 100
Ciclesonide 160
Mometasone furoate Not studied below age 4 years
Triamcinolone acetonide Not studied in this age group
Dr. Ochoa
CRAIC Mty
Tratamiento inicial
SABA con espaciador
Corticoesteroides iniciados por el familiar
Antagonista de receptores de leucotrienos.
Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2015.
Dr. Ochoa
CRAIC Mty
Algoritmo de
tratamiento de
niños mayores
de 2 años
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B.
Bacharier et al. Allergy. Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty
Tratamiento
Menores de 2 años
Existe información muy limitada, por lo que el diagnóstico y
tratamiento es difícil.
Una revisión de Cochrane no encontró evidencia clara del
beneficio de tratamiento con B2-agonistas, con información en
conflicto en otros estudios.
Estudios aleatorizados doble-ciego en lactantes con asma leve
persistente o grave con corticoesteroides nebulizados
demostraron menos síntomas nocturnos y menos
exacerbaciones.
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al. Allergy. Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty
Dr. Ochoa
CRAIC Mty
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al. Allergy. Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al. Allergy. Volume 63 Issue 1 Page 5-34, January 2008
Dr. Ochoa
CRAIC Mty
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report”, L. B. Bacharier et
al. Allergy. Volume 63 Issue 1 Page 5-34, January 2008