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				OR	REPRODUCE!
			ALTER	OR
		NOT	ALTER
	DO	NOT
	DO
	-		®
	MATERIAL		®
COPYRIGHTED	MATERIAL
COPYRIGHTED

GLOBAL STRATEGY FOR

ASTHMA MANAGEMENT AND PREVENTION

U PDATED 2009

				OR	REPRODUCE!
			ALTER	OR
		NOT	ALTER
	DO	NOT
	DO
	-
COPYRIGHTED	MATERIAL
COPYRIGHTED

Global Strategy for Asthma Management and Prevention The GINA reports are available on www.ginasthma.org.

Global Strategy for Asthma Management and Prevention 2009 (update)

GINA EXECUTIVE COMMITTEE*

GINA SCIENCE COMMITTEE*

Eric D. Bateman, MD, Chair

University Cape Town Lung Institute

Cape Town, South Africa

Louis-Philippe Boulet, MD

Hôpital Laval

Sainte-Foy , Quebec, Canada

Alvaro A. Cruz, MD

Federal University of Bahia

School of Medicine

Salvador, Brazil

Mark FitzGerald, MD

University of British Columbia

Vancouver, BC, Canada

Tari Haahtela, MD

Helsinki University Central Hospital

Helsinki, Finland

Mark L. Levy, MD

University of Edinburgh

London England, UK

Paul O'Byrne, MD

McMaster University

Ontario, Canada

Gary W. Wong, MD

Ken Ohta, MD, PhD		DO
Teikyo University School of Medicine		DO
Tokyo, Japan
Pierluigi Paggiaro, MD		-
University of Pisa		-
Pisa, Italy	MATERIAL
Pisa, Italy
Soren Erik Pedersen, M.D.
Kolding Hospital
Kolding, Denmark
Manuel Soto-Quiroz, MD
Hospital Nacional de Niños
San José, Costa Rica
COPYRIGHTED

Chinese University of Hong Kong

Hong Kong ROC

Mark FitzGerald, MD, Chair

University of British Columbia

Vancouver, BC, Canada

Neil Barnes, MD	REPRODUCE!
London Chest Hospital
London, England, UK
Peter J. Barnes, MD
National Heart and Lung Institute
London, England, UK

Eric D. Bateman, MD

University Cape Town Lung Institute

Cape Town, South Africa

Allan Becker, MD	OR
University of Manitoba
Winnipeg, Manitoba, Canada
ALTER
Jeffrey M. Drazen, MD
Harvard Medical School
Boston, Massachusetts, USA

Robert F. Lemanske, Jr., M.D.

University of Wisconsin

NOTSchool of Medicine

Madison, Wisconsin, USA

Paul O'Byrne, MD

McMaster University

Ontario, Canada

Ken Ohta, MD, PhD

Teikyo University School of Medicine

Tokyo, Japan

Soren Erik Pedersen, M.D.

Kolding Hospital

Kolding, Denmark

Emilio Pizzichini, MD

Universidade Federal de Santa Catarina

Florianópolis, SC, Brazil

Helen K. Reddel, MD

Woolcock Institute of Medical Research

Camperdown, NSW, Australia

Sean D. Sullivan, PhD

Professor of Pharmacy, Public Health

University of Washington

Seattle, Washington, USA

Sally E. Wenzel, M.D.

University of Pittsburgh

Pittsburgh, Pennsylvania, USA

Heather J. Zar, MD

University of Cape Town

Cape Town, South Africa

*Disclosures for members of GINA Executive and Science Committees can be found at: http://www.ginasthma.com/Committees.asp?l1=7&l2=2

PREFACE

Asthma is a serious global health problem. People of allIn spite of these dissemination efforts, internat ages in countries throughout the world are affectedsurveysby thisprovide direct evidence for suboptimal asth chronic airway disorder that, when uncontrolled, can placecontrol in many countries, despite the availability of

severe limits on daily life and is sometimes fataleffective. The		therapies. It is clear that if recommenda
		REPRODUCE!
prevalence of asthma is increasing in most countries,contained within this report are to improve care of peop
especially among children. Asthma is a significant burden,
	with asthma, every effort must be made to encourage
not only in terms of health care costs but also of lost
	health care leaders to assure availability of and access
productivity and reduced participation in family life.
	medications, and develop means to implement effectiv
	asthma management programs including the use of
During the past two decades, we have witnessed manyappropriate tools to measure success.
scientific advances that have improved our understanding
of asthma and our ability to manage and control it	In 2002, the GINA Report stated that “it is reasonable to
effectively. However, the diversity of national health care
	expect that in most patients with asthma, control of t
service systems and variations in the availability of asthma
	disease can, and should be achieved and maintained.”
therapies require that recommendations for asthma care
be adapted to local conditions throughout the global	To meet this challenge, in 2005, Executive Committee
	recommended preparation of a new report not only to
community. In addition, public health officials require
information about the costs of asthma care, how to	incorporate updatedORscientific information but to im
	an approach to asthma management based on asthma
effectively manage this chronic disorder, and education
	control, rather than asthma severity. Recommendations

methods to develop asthma care services and programs assess, treat and maintain asthma control are provided i
responsive to the particular needs and circumstances
		this document. The methods used to prepare this
within their countries.		documentALTERare described in the Introduction.
In 1993, the National Heart, Lung, and Blood Institute		It is a privilege for me to acknowledge the work of the
collaborated with the World Health Organization to		It is a privilege for me to acknowledge the work of the
collaborated with the World Health Organization to		many people who participated in this update project, as
	DO	many people who participated in this update project, as
convene a workshop that led to a Workshop Report:	DO	NOT
Global Strategy for Asthma Management and Prevention	.	well as to acknowledge the superlative work of all who
This presented a comprehensive plan to manage asthmahave contributed to the success of the GINA program.
with the goal of reducing chronic disability- and premature
the same time assuring a mechanismMATERIALto incorporate the
		The GINA program has been conducted through

deaths while allowing patients with asthma to lead unrestricted educational grants from AstraZeneca,
productive and fulfilling lives.	Boehringer Ingelheim, Chiesi Group, GlaxoSmithKline,

	Meda Pharma, Merck, Sharp & Dohme, Mitsubishi Tanabe
At the same time, the Global Initiative for Asthma (GINA)
	Pharma, Novartis, Nycomed, PharmAxis and Schering-
was implemented to develop a network of individuals,
	Plough. The generous contributions of these companie
organizations, and public health officials to disseminate
	assured that Committee members could meet together t
information about the care of patients with asthma while at
	discuss issues and reach consensus in a construct
2001) COPYRIGHTEDwhich has gained increasing attention each year to
	timely manner. The members of the GINA Committees
results of scientific investigations into asthma care.
Publications based on the GINA Report were prepared	are, however, solely responsible for the statements an
and have been translated into languages to promote	conclusions presented in this publication.
international collaboration and dissemination of	GINA publications are available through the Internet
information. To disseminate information about asthma
	(http://www.ginasthma.org).
care, a GINA Assembly was initiated, comprised of asthma
care experts from many countries to conduct workshops
with local doctors and national opinion leaders and to
seminars at national and international meetings. In
addition, GINA initiated an annual World Asthma Day (in
raise awareness about the burden of asthma, and to	Eric Bateman, MD
initiate activities at the local/national level to educateChair,GINA Executive Committee
families and health care professionals about effectiveUniversity of CapeTown Lung Institute
methods to manage and control asthma.	Cape Town, South Africa

GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION

TABLE OF CONTENTS

.........................................................................PREFACE				ii		...................................................CLINICAL DIAGNOSIS				16
METHODOLOGY AND SUMMARY OF NEW						Medical History...........................................................					16
METHODOLOGY AND SUMMARY OF NEW						Symptoms ..............................................................			REPRODUCE!		16
RECOMMENDATION, 2007 UPDATE				vi		Cough variant asthma			REPRODUCE!		16
RECOMMENDATION, 2007 UPDATE	.........................			vi		Cough variant asthma			............................................		16
INTRODUCTION				x		Exercise-Induced bronchospasm ...........................					17
INTRODUCTION				x		Physical Examination .................................................					17
CHAPTER 1. DEFINITION AND OVERVIEW				1		Tests for Diagnosis and Monitoring ............................					17
CHAPTER 1. DEFINITION AND OVERVIEW	..................			1		Measurements of lung function...............................					17
KEY POINTS			2			Spirometry..............................................................					18
KEY POINTS			2			Peak expiratory flow...............................................					18
DEFINITION				2		Measurement of airway responsiveness................					19
DEFINITION				2		Non-Invasive markers of airway inflammation					19
						Non-Invasive markers of airway inflammation				........	19
THE BURDEN OF ASTHMA		3				Measurements of allergic status.............................					19
THE BURDEN OF ASTHMA		3					OR
							OR
Prevalence, Morbidity and Mortality .............................				3		3 DIAGNOSTIC CHALLENGES AND
Social and Economic Burden .......................................				3		DIFFERENTIAL DIAGN SIS.......................................				20
.....................................................................Obesity				5		ALTER					20
FACTORS INFLUENCING THE DEVELOPMENT AND						Children 5 Years and Younger ...................................					20
EXPRESSION OF ASTHMA		4				..........................................Older Children and Adults					20
EXPRESSION OF ASTHMA		4				The Elderly					21
Host Factors				4		The Elderly					21
Host Factors				4		Occupational Asthma					21
Genetic				4		Occupational Asthma					21
Genetic				4		Distinguishing Asthma from COPD					21
						Distinguishing Asthma from COPD					21
Sex ...........................................................................				5		NOTPhenotype..................................................................					22
Environmental Factors					5	.....................................CLASSIFICATION OF ASTHMA			22
Environmental Factors					5	Etiology					22
Allergens				5		Etiology					22
Allergens				5
Infections ..................................................................				5		Asthma Control					22
Occupational sensitizers		-		5		Asthma Control					22
Occupational sensitizers		-		5
Tobacco smoke ........................................................	MATERIAL		DO6			Asthma Severity .........................................................					23
Outdoor/Indoor air pollution......................................				6		REFERENCES				23
Diet				7		REFERENCES				23
Diet				7
MECHANISMS OF ASTHMA............................................		7				CHAPTER 3. ASTHMA MEDICATIONS			........................		27
Airway Inflammation In Asthma ....................................						7
Inflammatory cells....................................................				7		KEY POINTS ..................................................................				28
Inflammatory mediators ............................................				7		INTRODUCTION				28
Structural changes in the airways.............................				8		INTRODUCTION				28
CHAPTERCOPYRIGHTED2. DIAGNOSIS AND LASSIFICATION			.....15			..................................................................Anti-IgE					32
Pathophysiology...........................................................				8		ASTHMA MEDICATIONS: ADULTS			28
Airway hyperresponsiveness....................................				8		ASTHMA MEDICATIONS: ADULTS			28
Special Mechanisms ....................................................				8		Route of Administration ..............................................					28
Acute exacerbations .................................................				8		Controller Medications................................................					29
Nocturnal asthma .....................................................				9		Inhaled glucocorticosteroids...................................					29
Irreversible airflow limitation.....................................				9		Leukotriene modifiers.............................................					30
Difficult-to-treat asthma............................................				9		Long-acting inhaled		2 -agonists .............................			30
Smoking and asthma ................................................				9		Theophylline...........................................................					31
REFERENCES		9				Cromones: sodium cromoglycate and
REFERENCES		9				nedocromil sodium ........................................					31
						Long-acting oral 2 -agonists...................................					32
KEY POINTS			16			Systemic glucocorticosteroids................................					32
KEY POINTS			16			Oral anti-allergic compounds..................................					32
INTRODUCTION ............................................................		16				Other controller therapies.......................................					32
						Allergen-specific immunotherapy............................					33

iii

...................................................Reliever Medications							34
Rapid-acting inhaled 2 -agonists............................							34		ASTHMA PREVENTION.................................................			54
Systemic glucocorticosteroids................................							34
Anticholinergics......................................................							34		PREVENTION OF ASTHMA SYMPTOMS AND
Theophylline...........................................................							35			EXACERBATIONS....................................................		55
Short-acting oral	2 -agonists..................................						35	35		Indoor Allergens .......................................................			55
Complementary and Alternative Medicine...................								35		Domestic mites .......................................................	REPRODUCE!		55
ASTHMA TREATMENT: CHILDREN			35							Furred animals	REPRODUCE!		55
										Furred animals			55
										Cockroaches ..........................................................			55
Route of Administration		..............................................						35		Fungi......................................................................			56
Controller Medications................................................							36			Outdoor Allergens ......................................................			56
Inhaled glucocorticosteroids...................................							36			Indoor Air Pollutants ..................................................			56
Leukotriene modifiers.............................................							38			Outdoor Air Pollutants ................................................			56
Long-acting inhaled 2 -agonists .............................							38			Occupational Exposures ............................................			56
Theophylline...........................................................							39			Food and Food Additives ...........................................			56
Cromones: sodium cromoglycate and nedocromil										Drugs .........................................................................			57
sodium .........................................................							39			Influenza Vaccination .................................................			57
Long-acting oral	...................................2 -agonists						39			Obesity.......................................................................			57
Systemic glucocorticosteroids................................							39			Emotional Stress ........................................................			57
Reliever Medications...................................................							40			Other Factors ThatORMay Exacerbate Asthma .............			57
Rapid-acting inhaled 2 -agonists and short-acting
oral 2 -agonists ..............................................							40		COMPONENT 3: ASSESS, TREAT AND MONITOR
Anticholinergics......................................................							40		ASTHMA ......................................................................				57
								NOT
REFERENCES ...............................................................			40						KEY POINTSALTER..................................................................			57
CHAPTER 4. ASTHMA MANAGEMENT AND									I	TRODUCTION ............................................................		57
PREVENTION ................................................................							49
INTRODUCTION ............................................................						DO			ASSESSING ASTHMA CONTROL.................................			58
				-					TREATING TO ACHIEVE CONTROL			58
COMPONENT 1: DEVELOP PATIENT/		MATERIAL							TREATING TO ACHIEVE CONTROL			58
		MATERIAL								Treatment Steps for Achieving Control			58
										Treatment Steps for Achieving Control			58
DOCTOR PARTNERSHIP	...........................................						50			Step 1: As-needed reliever medication ..................			58
KEY POINTS					50					Step 2: Reliever medication plus a single
KEY POINTS					50					controller.........................................................			60
INTRODUCTION				50						Step 3: Reliever medication plus one or two
INTRODUCTION				50						controllers.......................................................			60
ASTHMA EDUCATION			51							Step 4: Reliever medication plus two or more
ASTHMA EDUCATION			51							controllers.......................................................			61
COPYRIGHTED									52	Step 5: Reliever medication plus additional
At the Initial Consultation...........................................									52	Step 5: Reliever medication plus additional
Personal Asthma Action Plans ..................................							52			controller options............................................			61
Follow-up and Review ...............................................							52
Improving Adherence ................................................							52		MONITORING TO MAINTAIN CONTROL ......................			61
Self-Management in Children ....................................								52		Duration and Adjustments to Treatment......................			61
THE EDUCATION OF OTHERS			53							Stepping Down Treatment When Asthma Is
THE EDUCATION OF OTHERS			53							Controlled.................................................................			62
COMP NENT 2: IDENTIFY AND REDUCE EXPOSURE										Stepping Up Treatment In Response To Loss Of
COMP NENT 2: IDENTIFY AND REDUCE EXPOSURE										Control .....................................................................			62
TO RISK FACTORS	....................................................						54			Difficult-to-Treat-Asthma .............................................			63
KEY POINTS ..................................................................					54
INTRODUCTION				54					COMPONENT 4 - MANAGE ASTHMA
INTRODUCTION				54					EXACERBATIONS ......................................................				64

		Utilization and Cost of Health Care Resources		.........89
KEY POINTS ..................................................................	64	Determining the Economic Value of Interventions
		Asthma ...................................................................	90
INTRODUCTION ............................................................	64
		GINA DISSEMINATION/IMPLEMENTATION
ASSESSMENT OF SEVERITY.......................................	65	RESOURCES ............................................................	90

MANAGEMENT–COMMUNITY SETTINGS		65				REFERENCES			REPRODUCE!
MANAGEMENT–COMMUNITY SETTINGS		65				REFERENCES			91
Treatment...................................................................					66
Bronchodilators ......................................................				66
Glucocorticosteroids...............................................				66
MANAGEMENT–ACUTE CARE SETTINGS ..................	66
Assessment ................................................................					66
Treatment....................................................................					68
Oxygen ...................................................................				68
Rapid-acting inhaled 2 –agonists...........................				68				OR
Epinephrine ............................................................				68
Additional bronchodilators ...........................................				69		68	ALTER
Sedatives...............................................................				69			ALTER
Systemic glucocorticosteroids................................				68
Inhaled glucocorticosteroids...................................				69
Magnesium .............................................................				69
Helium oxygen therapy...........................................				69
Leukotriene modifiers.............................................				69		NOT
Criteria for Discharge from the Emergency						NOT
Criteria for Discharge from the Emergency
Department vs. Hospitalization.................................			DO			69
COMPONENT 5. SPECIAL CONSIDERATIONS			DO
COMPONENT 5. SPECIAL CONSIDERATIONS		..........		70
Pregnancy.....................................................................		-		70
Surgery .........................................................................		-			70
Aspirin-Induced Asthma ................................................	MATERIAL				72
Rhinitis, Sinusitis, And Nasal Polyps .............................						71
Rhinitis...................................................................				71
Sinusitis..................................................................				71
Nasal polyps...........................................................				71
Occupational Asthma ....................................................					71
Respiratory Infections ...................................................						72
Gastroesophageal Reflux..............................................					72
COPYRIGHTED					73
Anaphylaxis and Asthma...............................................					73
REFERENCES ...............................................................		73
CHAPTER 5. IMPLEMENTAT ON OF ASTHMA
GUIDELINES IN HEALTH SYSTEMS	.........................			87
KEY POINTS ..................................................................		88
INTRODU TION ............................................................		88
GUIDELINE IMPLEMENTATION STRATEGIES ............		88
ECONOMIC VALUE OF INTERVENTIONS AND
GUIDELINE IMPLEMENTATION IN ASTHMA...........		89

METHODOLOGY AND SUMMARY OF NEW RECOMMENDATIONS GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION: 2009

UPDATE*

	REPRODUCE!
When the Global Initiative for Asthma (GINA) program wasdiscuss each publication that was felt would have an
initiated in 1993, the primary goal was to produce	impact on asthma management and prevention by at least

recommendations for asthma management based on the 1 member of the Committee, and to reach a consensus on best scientific information available. Its firsthreport,changes in the report. In the absence of consensu

NHLBI/WHO Workshop Report: Global Strategy for		disagreements were decided by an open vote of the ful
Asthma Management and Prevention	was issued in 1995	committee.
and revised in 2002 and 2006. These reports, and their
companion documents, have been widely distributed Summaryand of Recommendations in the 2009 Update:
translated into many languages. The 2006 report was		Between July 1, 2008 and June 30, 2009, 392 articles met
based on research published through June, 2006 and can		the search criteria; 10 additional publications were bro
be found on the GINA websitewww.(ginasthma.org ).		to the attention of the committee. Of the 402 articles,
		OR
		papers were identified as having an impact on the GINA

recommendations in the GINA documents related to changingALTERthe text or introducing a concept requiring management and prevention, and to post yearly updatesrecommendation to the report. The summary is reported

The GINA Science Committee was established in 2002 toReport (updated 2009) that was posted on the website in review published research on asthma management and December 2009 either by: 1) confirming, that is, adding to prevention, to evaluate the impact of this research onor replacing an existing reference, or 2) modifying, th

on the GINA website. The first update of the 2006 reportin three segments: A) Modifications in the text; B) (2007 update) included the impact of publications fromReferences that provided confirmation or an update of

update included a Pub Med search using search fieldsPrevention in Children 5 Years and Younger was released

established by the Committee:asthma,1) All Fields, All	in early 2009 (can be found on www.ginasthma.org).
ages, only items with abstracts, Clinical rial, Human,	Accordingly, the Executive Summary “Managing Asthma i
sorted by Authors;and 2) asthma AND systematic , All	Children 5 Years and Younger” that appeared on pages

July 1, 2006 through June 30, 2007; the 2008 updated			previous recommendations; and C) Changes or
			NOT
included the impact of publications from July 1, 2007 modifications to the text.
through June 30, 2008. This 2009 update includes the
impact of publications from July 1, 2008 through June 30,Asthma in Children 5 Years and Younger: In 2008, a
		DO
2009.	-		number of pediatric experts developed a report which
2009.			number of pediatric experts developed a report which
			focused on asthma care in children 5 years and younger.
Methods:The methodology used to produce this 2009			The Global Strategy for Asthma Management and
	MATERIAL

fields, ALL ages, only items with abstracts, Human, xivsorted–xvii is deleted – see section C. by COPYRIGHTEDauthor. In addition, publications in peer review journals

not captured by Pub Med could be submitted to indiviAsthmadual Control: In review of the published literature, members of the Committee providing an abstract and theCommittee determined that many changes were required full paper were submitted in (or translated into) Englishinthe.segment “Classification of Asthma.” According

new segment appears beginning on page 22 – see section

All members of the Committee received a summary of D.1). citations and all abstracts. Each abstract was assigned to

at least two Committee members, although all membersEvidence Reviews: In the preparation of GINA reports, were offered the opportunity to provide an opinion onincludingay this 2009 update, levels of evidence has bee abstract. Members evaluated the abstract or, up to her/hiscompleted using four categories as described on page x judgment, the full publication, by answering specificThecommittewrienhas had extensive discussions inter

questions from a short questionnaire, and to indicateaswelliftheaswith proponents of a new methodology for

scientific data presented impacted on recommendationsdescribing recommendations (the GRADE system). The

the GINA report. If so, the member was asked to	implications for the widespread adaptation of this sy
specifically identify modifications that shouldhasbe beenmade.exploredThe by the Committee with regard to
entire GINA Science Committee met twice yearly to	resource implications, especially given the already

*The Global Strategy for Asthma Management and Prevention (updated 2009), the updated Pocket Guides and the complete list of references examined by the Comm available on the GINA website www.ginasthma.org.

†Members (2008-2009): M. FitzGerald, Chair; P. Barnes, N. Barnes, E. Bateman, A. Becker, J. Drazen, R. Lemanske, P. OiByrne, K. Ohta, S. Pedersen, E. Pizzichini, H. Reddel, S. Sullivan, S. Wenzel, H. Zar.

rigorous method of reviewing the literature and updatingAS,Buist AS, et al. Asthma drug use and the recommendations that is currently in place. The development of Churg-Strauss syndrome (CSS). committee has decided that it would be inappropriatePharmcoepidemiologyto and Drug Safety. 2007;16:620-26. implement this methodology for all the recommendations

within GINA and recommended instead to use the methodPg 31,- left column, paragraph 1, insert: …does not ology, selectively, especially where the balance betweenincrease the risk of asthma-related hospitalizations214 … efficacy and cost effectiveness is unclear or whereReferencethere214. is Jaeschke R, O'Byrne PM, Mejza F, Nair controversy with regard to the recommendation. The P, Lesniak W, Brozek J, Thabane L, Cheng J,

Committee applied GRADE to two questions (see sectionSchünemann HJ, Sears MR, Guyatt G. The safety of long-

D.2) and will continue to explore the use of GRADE-like	acting beta-agonists among patients with asthma usi
methodology for issues that require more in-depth	inhaled corticosteroids: systematic review and
evaluation.	metaanalysisAm. J Respir Crit Care Med . 2008 Nov
	15;178(10):1009-16. Epub 2008 Sep 5.
A. Modifications in the text:
	Pg 34, left column, end of paragraph 1, insert: Data on a
Pg 19, right column, insert end of first paragraph:although	human monoclonal antibody against tumor necrosis fact

it has been shown that the use of FeNo as a measure of(TNF)-alpha suggest that the risk benefit equation do
asthma control does not improve control or enable			REPRODUCE!
		not favor the use of this class of treatments in sev
	55	216	Wenzel SE, Barnes PJ,
reduction in dose of inhaled glucocorticosteroid.		asthma . Reference 216.
		ALTER
Reference 55.	Szefler SJ, Mitchell H, Sorkness CA,	Bleecker ER, BousquetORJ, Busse W, Dahlén SE, et al; T03
Gergen PJ, O'Connor GT, Morgan WJ, et al. Management		Asthma Investigators. A randomized, double-blind,

of asthma based on exhaled nitric oxide in addition toplacebo-controlled study of tumor necrosis factor-alpha guideline-based treatment for inner-city adolescentsblockadeand in severe persistent asthmaAm J Respir. Crit

young adults: a randomised controlled trial. Lancet. 2008Care Med. 2009 Apr 1;179(7):549-58. Epub 2009 Jan 8.

Sep 20;372(9643):1065-72.			NOT

Pg 30, left column, line 6, insert:although there appear to			Pg 35, right column, beginning of paragraph 4, insert:
			Dietary supplements, including seleniumaretherapynot
				197
be differences in response according to		DO	of proven benefit and the use of a low sodium diet as a
symptom/inflammation phenotype. Reference 212 .			adjunctive therapy to normal treatment has no additiona
212
Haldar P, Pavord ID, Shaw DE, Berry MA, Thomas M,			therapeutic benefit in adults with asthma. In addit
	-		no effect on bronchial reactivity to methacholine.
Brightling CE, Wardlaw AJ, Green RH. Cluster analysis
				217
and clinical asthma phenotypesAm J Respir.	Crit Care		Reference 217.	Pogson ZE, Antoniak MD, Pacey SJ,
MATERIAL			Lewis SA, Britton JR, Fogarty AW. Does a low sodium
Med . 2008 Aug 1;178(3):218-24. Epub 2008 May 14
			diet improve asthma control? A randomized controlled tri
Pg 30, left column, line 11 from end, insert:	meta-		Am J Respir Crit Care Med. 2008 Jul 15;178(2):132-8.

analysis of case-control studies of non-vertebral fracturesEpub2008May 1. in adults using inhaled glucocorticosteroids (BDP or

equivalent) indicated that in older adults, the relativePg 38, Figurerisk of3.6, delete last statement and insert: non-vertebral fractures increases by about 12% for eachInhaled glucocorticosteroid use has the potential for 1000 µg/day increase in the dose BDP or equivalent but reducing bone mineral accretion in male children that the magnitude of this risk was considerably lessprogressingthan through puberty, but this risk is like other common risk factors for fracture in the older weighed by the ability to reduce the amount of oral

adult213. Reference 213.	Weatherall M, James K, Clay	218
		corticosteroids used in these.childrenReference 218.
J, Perrin K, Masoli M, Wijesinghe M, Beasley R. Dose-		Kelly HW, Van Natta ML, Covar RA, Tonascia J, Green
response relationship for risk of non-vertebral fractureRP,StrunkwithRC;CAMP Research Group. Effect of long-
inhaled corticosteroidsClin Exp. Allergy. 2008		term corticosteroid use on bone mineral density in
Sep;38(9):1451-8. Epub 2008 Jun 3.		children: a prospective longitudinal assessment in
		childhood Asthma Management Program (CAMP) study.
Pg 30, right column, last paragraph delete last sentence		Pediatrics. 2008 Jul;122(1):e53-61.
and references 52-54 and replace with: No association
was found between Churg-Strauss syndrome and		Pg 39, left column, end of first paragraph, insert:
COPYRIGHTED
leukotriene modifiers, after controlling for asthmaMontelukadrugse,t has not been demonstrated to be an effect

although it is not possible to rule out modest associnhaledationsglucocorticosteroid sparing alternative in ch
given that Churg-Strauss syndrome is so rare and so with moderate-to-severe persistent.asthmaReference
	219
highly correlated with asthma52severity.NewReference	219. Strunk RC, Bacharier LB, Phillips BR, Szefler SJ,
52 . Harrold LR, Patterson K, Andrade SE, Dube T, Go	Zeiger RS, Chinchilli VM, et al.; CARE Network.

vii

Azithromycin or montelukast as inhaled corticosteroidblockers,- within 24 hours of hospital admission, for a sparing agents in moderate-to-severe childhood asthmaacute coronary event, have lower in-hospital mortality

studyJ .Allergy Clin Immunol. 2008 Dec;122(6):1138-	rates . Reference 366.	Babu KS, Gadzik F, Holgate
	366, 367
1144.e4. Epub 2008 Oct 25.	ST. Absence of respiratory effects with ivabradine i
	patients with asthma. Br J Clin Pharmacol. 2008
Pg 51, right column, end of last paragraph, insert:Lay	Jul;66(1):96-101. Epub 2008 Mar 13.	Reference 367.
		REPRODUCE!
educators can be recruited and trained to deliver a discreteOlenchock BA, Fonarow GG, Pan W, Hernandez A,
area of respiratory care (for example, asthma self-	Cannon CP; Get With The Guidelines Steering Committee.
management education) with comparable outcomes to	Current use of beta blockers in patients with reacti

those achieved by primary care based practice362nursesairway disease who are hospitalized with acute coronary

(Evidence B).		syndromesAm. J Cardiol . 2009 Feb 1;103(3):295-300.
Reference 362.	Partridge MR, Caress AL, Brown C,	Epub 2008 Nov 19.
Hennings J, Luker K, Woodcock A, Campbell M. Can lay

people deliver asthma self-management education as Pg 62, left column, last paragraph, delete sentence and effectively as primary care based practice nurses?replace with:However, this is more likely to lead to loss

Thorax . 2008 Sep;63(9):778-83. Epub 2008 Feb 15.)	asthma control (Evidence B ). Reference 368:
	137, 368
	Godard P, Greillier P, Pigearias B, Nachbaur G,

Pg 52, right column, last paragraph, delete first sentence Desfougeres JL, Attali V. Maintaining asthma control in and replace with:Although interventions for enhancingpersistent asthma: comparison of three strategies in

medication adherence have been developed, studies of				ALTER
medication adherence have been developed, studies of			month double-blindORrandomised study. Respir Med. 2008
	363
adults and children with34 asthmahaveshown that around			Aug;102(8):1124-31. pub 2008 Jul 7.
50% of those on long-term therapy fail to take medications
as directed at least part of theReferencetime.363.			Pg 72, left column, end of third paragraph, insert: Adult
Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X.			with asthma may be at increased risk of serious
			NOT
Interventions for enhancing medication adherence.pneumococcal disease. Reference 370 . Juhn YJ, Kita
					370
Cochrane Database Syst Rev	. 2008 Apr 16;(2):CD000011		H, Yawn BP, Boyce TG, Yoo KH, McGree ME, Weaver AL,
			Wollan P, Jacobson RM. Increased risk of serious
Pg 55, left column, end of first paragraph, insert:Patients			pneumococcal disease in patients withJasthmaAllergy.
		DO
with well-controlled asthma are less likely to experienceClin Immunol. 2008 Oct;122(4):719-23. Epub 2008 Sep
exacerbations than those whose asthma is not well-			13.
controlled.	-
364
indicated and insert:InstallationMATERIALof non-polluting, more
Reference 364 : Bateman ED, Bousquet J, Busse WW,			Pg 89, right column, first paragraph, insert:Use of
Clark TJ, Gul N, Gibbs M, Pedersen S; GOAL Steering			administrative datasets (e.g., dispensing records) or

Committee and Investigators. Stability of asthma controlhealth care utilization can help to identify at-risk p

	23
with regular treatment: an analysis of the Gaining toOptimalaudit the quality of health. Referencecare 23 .
Asthma controL (GOAL) study. Allergy. 2008	Bereznicki BJ, Peterson GM, Jackson SL, Walters EH,
Jul;63(7):932-8.	Fitzmaurice KD, Gee PR. Data-mining of medication
	records to improve asthma managementMed. J Aust.
Pg 56, left column, end of third paragraph delete as	2008 Jul 7;189(1):21-5.

effective heating (heat pump, wood pellet burner, fluB.Referencesd that provided confirmation or update of

gas) in the homes of children with asthma does not			previous recommendations:
significantly improve lung function but does significantly
reduce symptoms of asthma, days off school, healthcarePg 24: Right column, replace reference 32. Horvath I,
		365	Hunt J, Barnes PJ, Alving K, Antczak A, Baraldi E, et al.
utilization, and visits to a pharmacist.
Reference 365.	Howden-Chapman P, Pierse N, Nicholls		Exhaled breath condensate: methodological
			recommendations and unresolved questionsEur Respir.	J
S, Gillespie-Bennett J, Viggers H, Cunningham M, et al.
			2005;26:523-48.
Effects of improved home heating on asthma in community
dwelling children: randomized controlledBMJ .trial2008.			Pg 30: Left column, insert reference 211. O'Byrne PM,
Sep 23;337:a1411. doi: 10.1136/bmj.a1411.
COPYRIGHTED			Naya IP, Kallen A, Postma DS, Barnes PJ. Increasing
			doses of inhaled corticosteroids compared to adding lon
Pg 57, left column, end of first paragraph, insert:Beta

blockers have a proven benefit in the management of acting inhaled beta2-agonists in achieving asthma con

Chest. 2008 Dec;134(6):1192-9. Epub 2008 Aug 8. patients with acute coronary syndromes and for secondary

prevention of coronary events. Data suggest that patients with asthma who receive newer more cardio-selective beta

viii

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