POCKET GUIDE FOR

ASTHMA MANAGEMENT

AND PREVENTION

POCKET GUIDE FOR

ASTHMA MANAGEMENT

AND PREVENTION

A Pocket Guide for Physicians and Nurses

Revised 2002

BASED ON THE WORKSHOP REPORT:

GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION

REVISED (2002)

NATIONAL INSTITUTES OF HEALTH

NATIONAL HEART, LUNG, AND BLOOD INSTITUTE

®

GINA POCKET GUIDE NEWfinal 4/3/03 12:13 PM Page cov1
GLOBAL INITIATIVE FOR ASTHMA

Executive Committee (2002) Dissemination Committee (2002)

Tim Clark, M.D., U.K., Chair Martyn R. Partridge, M.D., U.K., Chair

William Busse, M.D., U.S.A. Gabriel Anabwani, M.D., Botswana

Jean Bousquet, M.D., Ph.D., France Richard Beasley, M.D., New Zealand

Stephen T. Holgate, M.D., DSc., U.K. Hisbello Campos, M.D., Brazil

Claude Lenfant, M.D., U.S.A. Yu Zhi Chen, M.D., China

Paul O'Byrne, M.D., Canada Frode Gallefoss, M.D., Norway

Ken Ohta, M.D., Japan Michiko Haida, M.D., Japan

Martyn R. Partridge, M.D., U.K. Javaid A. Khan, M.D., Pakistan

Soren Pedersen, M.D., Denmark Ron Neville, M.D., U.K.

Albert L. Sheffer, M.D., U.S.A. Albert L. Sheffer, M.D., U.S.A.

Raj Singh, M.D., India Raj Singh, M.D., India

Wan Cheng Tan, M.D., Singapore Jeyaindaran Sinnadurai, M.D., Malaysia

Wan Cheng Tan, M.D., Singapore

Ron Tomlins, M.D., Australia

Onno van Schayck, M.D., Netherlands

Heather Zar, M.D., South Africa

Updated from the NHLBI/WHO Workshop Report:

Global Strategy for Asthma Management and Prevention issued January, 1995.

NIH Publication No. 02-3659

The 2002 report is available on: http://www.ginasthma.com

®

NATIONAL HEART, LUNG, 

AND BLOOD INSTITUTE

National Institutes of Health

GLOBAL INITIATIVE

FOR ASTHMA

®

GINA POCKET GUIDE NEWfinal 4/3/03 12:13 PM Page b1
1

TABLE OF CONTENTS

PREFACE ............................................................................................2

WHAT IS KNOWN ABOUT ASTHMA? ............................................ 4

DIAGNOSING ASTHMA ..................................................................6

Figure 1. Is it Asthma? ................................................................6

Figure 2. Peak Flow Meters: Uses and Technique ..........................7

CLASSIFY ASTHMA SEVERITY ..........................................................9

Figure 3. Classify Severity ..........................................................9

A SIX PART PROGRAM TO MANAGE AND 

CONTROL ASTHMA ........................................................................10

Part 1: Educate Patients To Develop a Partnership in

Asthma Care ................................................................10

Part 2: Assess and Monitor Asthma Severity........................12

Figure 4. Questions for Monitoring Asthma Care ........................13

Part 3: Avoid Exposure To Risk Factors ................................14 

Figure 5. Common Asthma Risk Factors and 

Actions to Reduce Exposure ........................................14 

Part 4: Establish Individual Medication Plans for 

Long-term Management in Children and Adults....15 

Select Medications..................................................................16 

Figure 6. Glossary of Asthma Medications..................................17

Figure 7. Estimated Comparative Daily Dosages for Inhaled

Glucocorticosteroids ....................................................19

Stepwise Approach to Long-term Management of Asthma....20

Figure 8. Recommended Medications by Level of Severity

Adults and Children Older Than 5 Years of Age ..........20

Figure 9. Recommended Medications by Level of Severity

Children Younger Than 5 Years of Age ........................21

Part 5: Establish Individual Plans To Manage 

Asthma Attacks ..........................................................22 

Figure 10. Severity of Asthma Attacks ........................................24

Figure 12. Management of an Asthma Attack: 

Home Treatment........................................................25

Figure 12. Management of Asthma Attacks: 

Hospital-Based Care..................................................26

Part 6: Provide Regular Followup Care ................................27

SPECIAL CONSIDERATIONS IN MANAGING ASTHMA..........27

GINA POCKET GUIDE NEWfinal 4/3/03 12:13 PM Page 1
PREFACE

Asthma is a major cause of chronic morbidity and mortality throughout the

world. The Global Initiative for Asthma was created to increase

awareness of asthma among health professionals, public health authorities,

and the general public, and to improve prevention and management

through a concerted worldwide effort. The Initiative prepares scientific

reports on asthma, encourages dissemination and adoption of the reports,

and promotes international collaboration on asthma research.

While asthma has been recognized for many years, public health officials

are concerned about recent and continuing increases in its prevalence. 

The Global Initiative for Asthma offers a framework for asthma 

management that can be adapted to local health care systems and

resources. Educational tools, such as laminated cards, or computer-based

learning programs can be prepared that are tailored to these systems and

resources. 

The Global Initiative for Asthma program publications include: 

• Workshop Report: Global Strategy for Asthma Management 

and Prevention (updated 2002). Scientific information and 

recommendations for asthma programs. NIH Publication No. 02-3659

• Pocket Guide for Asthma Management and Prevention. Summary of

patient care information for primary health care professionals.

(updated 2002). NIH Publication No. 02-3659A 

• Pocket Guide for Asthma Management and Prevention in 

Children. Summary of patient care information for pediatricians 

and other health care professionals. (Available fall 2002). 

NIH Publication No. 02-3659B 

• Asthma Management and Prevention: A Practical Guide for Public

Health Officials and Health Care Professionals. NIH Publication 

No. 96-3659B

• What You and Your Family Can Do About Asthma. An information

booklet for patients and their families. NIH Publication 

No. 96-3659C

2

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Publications are available from http://www.ginasthma.com. 

This Pocket Guide has been developed from the Workshop Report: Global

Strategy for Asthma Management and Prevention (updated March 2002).

Technical discussions of asthma, evidence levels, and specific citations from

the scientific literature are included in the Workshop Report. 

Acknowledgements:

Grateful acknowledgement is given for unrestricted educational grants 

from Altana, Andi-Ventis, AstraZeneca, Aventis, Bayer, Boehringer

Ingelheim, Chiesi Group, GlaxoSmithKline, Merck, Sharp & Dohme, ,

Mitsubishi-Pharma Corporation, Nikken Chemicals Co., LTD., Novartis,

Schering-Plough International, Sepracor and Viatris. The generous contributions of these companies assured that the workshop participants could

meet together and publications could be printed for wide distribution.

However, the workshop participants are solely responsible for the statements and conclusions in the publications.

3

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WHAT IS KNOWN 

ABOUT ASTHMA?

Unfortunately...asthma is one of the most common chronic diseases

worldwide and the prevalence is increasing, especially among children. 

Fortunately...asthma can be treated and controlled so that almost 

all patients can:

• Prevent troublesome symptoms night and day

• Prevent serious attacks

• Require little or no reliever medication

• Have productive, physically active lives

• Have (near) normal lung function.

■ Asthma causes recurring episodes of wheezing, breathlessness,

chest tightness, and coughing particularly at night or in the early

morning. 

■ Asthma is a chronic inflammatory disorder of the airways.

Chronically inflamed airways are hyperresponsive; they become 

obstructed and airflow is limited (by bronchoconstriction, mucus plugs,

and increased inflammation) when airways are exposed to various risk

factors.

■ Common risk factors include exposure to allergens such as domestic

dust mites (in bedding, carpets, and fabric-upholstered furnishings), 

animals with fur, cockroach, pollens and molds; occupational irritants;

tobacco smoke; air pollution; respiratory (viral) infections; exercise,

strong emotional expressions; chemical irritants and drugs (such as

aspirin and beta blockers). There is good evidence that asthma occurs in

families. 

■ Asthma severity can be intermittent, or it can be persistently mild, 

moderate, or severe. Severity varies among individuals, does not necessarily relate to the frequency or persistence of symptoms, and can change

in one individual over time. Treatment decisions are made based on

severity. 

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■ A stepwise approach to pharmacologic treatment to achieve and

maintain control of asthma should take into account current treatment,

pharmacologic properties and availability of anti-asthma treatments, and

economic considerations. 

■ Asthma attacks (or exacerbations) are episodic, but airway 

inflammation is chronically present. For many patients, medication 

must be taken every day to control symptoms, improve lung function, 

and prevent attacks. Medications may also be required to relieve acute

symptoms, such as wheezing, chest tightness, and cough. 

■ Asthma care requires a partnership between the patient and the health

care professional. The aim is to provide patients the ability to control

their asthma with guidance from the health care professional.

■ Asthma is not a cause for shame. Olympic athletes, famous leaders, other

celebrities, and ordinary people live successful lives with asthma.

■ Asthma may be preventable. For infants with a family history of 

asthma or atopy, it is thought that avoiding exposure to passive smoking

and to domestic dust mite, cat, and cockroach allergens may help prevent

the initial development of asthma. For adults, avoiding exposure to smoke

and to chemical sensitizers in the workplace is helpful.

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DIAGNOSING

ASTHMA 

Asthma can often be diagnosed on the basis of symptoms. However,

measurements of lung function, and particularly the reversibility of lung

function abnormalities, greatly enhance diagnostic confidence.

Figure 1. Is It Asthma?

Consider asthma if any of the following signs or symptoms are present.

■ Wheezing–high-pitched whistling sounds when breathing out–especially in 

children. (A normal chest examination does not exclude asthma.)

■ History of any of the following:

• Cough, worse particularly at night

• Recurrent wheeze

• Recurrent difficult breathing

• Recurrent chest tightness.

(Note: Eczema, hay fever or a family history of asthma or atopic diseases are often

associated with asthma.)

■ Symptoms occur or worsen at night, awakening the patient.

■ Symptoms occur or worsen in the presence of:

• Animals with fur • Exercise

• Aerosol chemicals • Pollen

• Changes in temperature • Respiratory (viral) infections

• Domestic dust mites • Smoke

• Drugs (aspirin, beta blockers) • Strong emotional expression

■ Reversible and variable airflow limitation–as measured by using a spirometer 

(FEV1 and FVC) or a peak expiratory flow (PEF) meter. When using a peak flow

meter, consider asthma if: 

• PEF increases more than 15 percent 15 to 20 minutes after inhalation of a

rapid-acting 2-agonist, or

• PEF varies more than 20 percent from morning measurement upon arising to 

measurement 12 hours later in patients taking a bronchodilator (more than 10

percent in patients who are not taking a bronchodilator), or

• PEF decreases more than 15 percent after 6 minutes of sustained running or

exercise.

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Figure 2. Peak Flow Meters: Uses and Technique

■ Lung function measurements assess airflow limitation and help diagnose and monitor

the course of asthma. 

■ To assess the level of airflow limitation, two methods are used. Peak flow meters

measure peak expiratory flow (PEF), and spirometers measure forced expiratory 

volume in 1 second (FEV1) and its accompanying forced vital capacity (FVC). The

accuracy of all lung function measurements depend on patient effort and correct 

technique. 

■ Several kinds of peak flow meters and spirometers are available, and the technique

for use is similar for all. To use a peak flow meter:

• Stand up and hold the peak flow meter without restricting movement of the marker.

Make sure the marker is at the bottom of the scale.

• Take a deep breath, put the peak flow meter in your mouth, seal your lips around

the mouthpiece, and breathe out as hard and fast as possible. Do not put your

tongue inside the mouthpiece.

• Record the result. Return the marker to zero.

• Repeat twice more. Choose the highest of the three readings.

■ Daily PEF monitoring for 2 to 3 weeks is useful, when it is available, for establishing

a diagnosis and treatment. If during 2 to 3 weeks a patient cannot achieve 80 percent of predicted PEF (predicted values are provided with all peak flow meters), it

may be necessary to determine a patient's personal best value, e.g. by a course of

oral glucocorticosteroid.

■ Long-term PEF monitoring is useful, along with review of symptoms, for evaluating 

a patient's response to therapy. PEF monitoring can also help detect early signs of

worsening before symptoms occur. 

Note: Examples of available peak flow meters and instructions for use of inhalers and

spacers can be found on www.ginasthma.com.

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Diagnostic challenges include the following:

■ Young children whose primary symptom is recurrent or persistent cough

or who wheeze with respiratory infections are often misdiagnosed as 

having bronchitis or pneumonia (including acute respiratory infection 

–ARI) and thus ineffectively treated with antibiotics or cough suppressants.

Treatment with asthma medication can be beneficial and diagnostic.

■ Many infants and young children who wheeze with viral respiratory 

infections may not develop asthma that persists through childhood. But

they may benefit from asthma medications for their wheezing episodes.

There is no certain way to predict which children will have persistent 

asthma, but allergy, a family history of allergy or asthma, and perinatal

exposure to passive smoke and allergens are more strongly associated

with continuing asthma.

■ Asthma should be considered if the patient's colds repeatedly "go to the

chest" or take more than 10 days to clear up, or if the patient improves

when asthma medication is given.

■ Tobacco smokers and elderly patients frequently suffer from chronic

obstructive pulmonary disease (COPD) with symptoms similar to asthma.

Yet they may also have asthma and benefit from treatment. Improvement

in PEF after asthma treatment is diagnostic.

■ Workers who are exposed to inhalant chemicals or allergens in the 

workplace can develop asthma and may be misdiagnosed as having

chronic bronchitis or chronic obstructive pulmonary disease. Early 

recognition (PEF measurements at work and home), strict avoidance of 

further exposure, and early treatment are essential.

■ Asthma attacks may be difficult to diagnose. For example, acute shortness

of breath, chest tightness and wheezing can also be caused by croup,

bronchitis, heart attacks, and vocal cord dysfunction. Using spirometry,

establishing reversibility of symptoms with bronchodilators, and assessing

the history of the attack (e.g. whether it was related to exposures that 

commonly make asthma worse) aid the diagnosis. A chest xray can help

rule out infection, large airway lesions, congestive heart failure, or 

aspiration of a foreign object.

8

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CLASSIFY ASTHMA 

SEVERITY

Classify asthma as intermittent, mild persistent, moderate persistent, or

severe persistent based on the combined assessments of symptoms and 

lung function. Severity of asthma will determine the type of

treatment required. 

When the patient is already on treatment, the classification of severity

should be based on the clinical features present and the step of the daily

medication regimen that the patient is currently on. 

• The presence of one of the features of severity is sufficient to place a

patient in that category.

• Patients at any level of severity–even intermittent asthma–can have 

severe attacks.

Figure 3: Classify Asthma Severity

Symptoms/Day Symptoms/Night PEF or FEV1

PEF variability

STEP 1

Intermittent

STEP 2

Mild Persistent

STEP 3

Moderate

Persistent

STEP 4

Severe Persistent

< 1 time a week

Asymptomatic and

normal PEF between

attacks

> 1 time a week 

but < 1 time a day

Attacks may affect

activity

Daily

Attacks affect 

activity 

Continuous

Limited physical

activity

≤ 2 times a month

> 2 times a month

> 1 time a week

Frequent

≥ 80%

< 20%

≥ 80%

20-30%

60%-80%

> 30%

≤ 60% 

> 30%

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A SIX-PART PROGRAM 

TO MANAGE AND 

CONTROL ASTHMA

Appropriate asthma care can help patients prevent most attacks, stay free

of troublesome night and day symptoms, and keep physically active. 

A six-part management program includes: 

Part 1. Educate patients to develop a partnership in asthma care.

Part 2. Assess and monitor asthma severity.

Part 3. Avoid exposure to risk factors. 

Part 4. Establish individual medication plans for long-term 

management in children and adults.

Part 5. Establish individual plans to manage asthma attacks.

Part 6. Provide regular followup care. 

The goals for successful management of asthma are:

• Minimal or no symptoms, including nighttime symptoms

• Minimal asthma episodes or attacks

• No emergency visits to physicans or hospitals

• Minimal need for reliever medications

• No limitations on physical activities and exercise

• Nearly normal lung function

• Minimal or no side effects from medication.

Part 1: Educate Patients To Develop a Partnership in

Asthma Care.

■ With your help, and the help of others on the health care team, patients

can be actively involved in managing their asthma to prevent problems

and can live productive, physically active lives. They can learn to:

• Avoid risk factors.

• Take medications correctly.

• Understand the difference between "controller" and "reliever" 

medications.

• Monitor their status using symptoms and, if available, PEF. 

• Recognize signs that asthma is worsening and take action.

• Seek medical help as appropriate.

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■ Working together, you and your patient should prepare a written

personal asthma management plan that is medically appropriate and

practical.

■ An asthma management plan should cover:

• Prevention steps for long-term control

– Asthma risk factors to avoid

– Daily medications to take

• Action steps to stop attacks

– How to recognize worsening asthma. List indicators such

as increasing cough, chest tightness, wheeze, difficult breathing,

sleep disturbance, or PEF below personal best despite increased

use of medications.

– How to treat worsening asthma. List the names and doses

of reliever medications and glucocorticosteroid tablets and when

to use them.

– How and when to seek medical attention. List indicators

such as an attack with sudden onset, shortness of breath while

resting or speaking a few words, feeling panicky, PEF below a

specified level, or a history of severe attacks. List the name, 

location, and telephone number of the physician's office or clinic

or hospital.

■ Educational methods should be appropriate for your patients. Using a

variety of methods–discussions (with a physician, nurse, outreach 

worker, counselor, or educator), demonstrations, written materials, group

classes, video or audio tapes, dramas, and patient support groups–helps

reinforce your education.

■ Ongoing education, presented at every patient visit, is the key to success

in all aspects of asthma management.

Sample self-management plans can be found on several web sites, e.g.

http://www.asthma.org.uk;

http://www.nhlbisupport.com/asthma/index.html; and

http://www.asthmanz.co.nz.

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Part 2: Assess and Monitor Asthma Severity.

■ Control of asthma requires continual long-term care and monitoring.

■ Monitoring includes review of symptoms and, as much as possible,

measurement of lung function.

• PEF monitoring at every physician visit, (spirometry is preferred but

not always available), along with review of symptoms, helps in 

evaluating the patient's response to therapy and adjusting treatment

accordingly. PEF consistently greater than 80 percent of the patient's

personal best suggests good control.

• Long-term PEF monitoring at home can help patients recognize early

signs of worsening asthma (PEF less than 80 percent of personal

best) before symptoms occur. Patients can act promptly according to

their personal asthma management plan to avoid serious attacks.

Home PEF monitoring is not always practical, but for patients who

cannot perceive symptoms and for those who have ever been hospitalized, home PEF monitoring has a high priority.

■ Regular visits (at 1- to 6-month intervals as appropriate) are essential,

even after control of asthma is established. At each visit review the 

questions in figure 4.

■ Compliance/adherence with asthma management plans is improved

when patients have the opportunity to talk about their concerns, fears,

and expectations related to their asthma.

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Action to consider:

Adjust medications and management plan as needed (step up or

step down). But first, compliance

should be assessed.

Action to consider:

Demonstrate correct technique.

Have patient demonstrate back.

Action to consider:

Adjust plan to be more practical.

Problem solve with the patient to

overcome barriers to following the

plan.

Action to consider:

Provide additional education to

relieve concerns and discussion to

overcome barriers.

13

Ask the patient:

Has your asthma awakened you at

night?

Have you needed more reliever 

medications than usual?

Have you needed any urgent medical

care?

Has your peak flow been below your

personal best?

Are you participating in your usual 

physical activities?

Ask the patient:

Please show me how you take your 

medicine.

Ask the patient, for example:

So that we may plan therapy, please 

tell me how often you actually take the

medicine.

What problems have you had following

the management plan or taking your

medication?

During the last month, have you ever

stopped taking your medicine because

you were feeling better?

Ask the patient:

What concerns might you have 

about your asthma, medicines, or 

management plan?

Figure 4. Questions for Monitoring Asthma Care

IS THE ASTHMA MANAGEMENT PLAN MEETING EXPECTED GOALS?

IS THE PATIENT USING INHALERS, SPACER, OR 

PEAK FLOW METERS CORRECTLY?

IS THE PATIENT TAKING THE MEDICATIONS AND AVOIDING RISK 

FACTORS ACCORDING TO THE ASTHMA MANAGEMENT PLAN?

DOES THE PATIENT HAVE ANY CONCERNS?

GINA POCKET GUIDE NEWfinal 4/3/03 12:13 PM Page 13
Part 3: Avoid Exposure to Risk Factors.

■ To improve the control of asthma and reduce medication needs, patients

should avoid exposure to risk factors (allergens and irritants that make

asthma worse). 

■ Specific immunotherapy, directed at treating an underlying allergy

to grass and other pollen, domestic mites, animal dander, or Alternaria,

may be considered when avoiding allergens is not possible or appropriate

medications fail to control asthma symptoms. Specific immunotherapy

should be performed only by health professionals trained in its use.

■ Primary prevention of asthma is not yet possible, but promising 

leads are being actively investigated. There is evidence that environmental

tobacco smoke exposure both prenatally and postnatally has an adverse

influence on the development of wheezing illnesses. 

Figure 5. Common Asthma Risk Factors and Actions to Reduce Exposure

RISK FACTOR

Domestic dust mite allergens (so

small they are not visible to the

naked eye)

Tobacco smoke (whether the patient

smokes or breathes in the smoke

from others)

Allergens from animals with fur

Cockroach allergen

Outdoor pollens and mold

Indoor mold

Physical activity

Drugs

ACTIONS

Wash bed linens and blankets weekly in hot

water and dry in a hot dryer or the sun.

Encase pillows and mattresses in air-tight 

covers. Replace carpets with linoleum or wood

flooring, especially in sleeping rooms. Use

vinyl, leather, or plain wooden furniture

instead of fabric-upholstered furniture. 

If possible, use vacuum cleaner with filters.

Stay away from tobacco smoke. Patients and

parents should not smoke.

Remove animals from the home, or at least

from the sleeping area.

Clean the home thoroughly and often. Use

pesticide spray–but make sure the patient is

not at home when spraying occurs.

Close windows and doors and remain indoors

when pollen and mold counts are highest.

Reduce dampness in the home; clean any

damp areas frequently.

Do not avoid physical activity. Symptoms can

be prevented by taking a rapid-acting inhaled

2-agonist, a cromone, or a leukotriene 

modifier before strenuous exercise.

Do not take beta blockers or aspirin or NSAIDs

if these medicines cause asthma symptoms.

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Part 4: Establish Individual Medication Plans for 

Long-term Management in Children and Adults.

■ A stepwise approach is used to classify asthma severity and guide

treatment. The number and frequency of medications increase (step up)

as the need for asthma therapy increases, and decreases (step down)

when asthma is under control.

Persistent asthma is more effectively controlled by long-term treatment 

to suppress and reverse the inflammation than by only treating acute

bronchoconstriction and related symptoms. Anti-inflammatory agents,

particularly inhaled glucocorticosteroids, are currently the

most effective long-term preventive medications and are

effective in reducing asthma attacks.

The recommended treatments are guidelines only. Local resources and 

individual patient circumstances determine specific therapy.

■ Gain control – There are two approaches to gaining control of asthma.

The first approach is preferred.

• Establish control promptly with a high level of therapy (for example,

add a short course of oral glucocorticosteroid and/or a higher dose

of inhaled glucocorticosteroids plus long-acting 2-agonist to the 

therapy that corresponds with the patient's level of asthma severity)

and then step down.

• Start treatment at the step most appropriate to the level of asthma

severity and step up if necessary.

■ Step up if control is not achieved and sustained. Generally, 

improvement should be achieved within 1 month. But first review the

patient's medication technique, compliance, and avoidance of risk factors. 

■ Step down if control is sustained for at least 3 months; follow a 

gradual stepwise reduction in treatment. The goal is to decrease 

treatment to the least medication necessary to maintain control.

■ Review treatment every 3 to 6 months once asthma is under control.

■ Consult with an asthma specialist when other conditions complicate

asthma (e.g., sinusitis), the patient does not respond to therapy, or 

treatment at steps 3 or 4 is required.

15

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GINA POCKET GUIDE NEWfinal 4/3/03 12:13 PM Page 15
Select Medications

■ Two types of medication help control asthma: controller medications

that keep symptoms and attacks from starting, and reliever medications that work quickly to treat attacks or relieve symptoms. 

■ Inhaled medications are preferred because of their high therapeutic

ratio: high concentrations of drug are delivered directly to the airways

with potent therapeutic effects and few systemic side effects.

• Devices available to deliver inhaled medication include pressurized

metered-dose inhalers (pMDIs), breath-actuated metered dose

inhalers, dry powder inhalers, and nebulizers. Spacer (or holding

chamber) devices make inhalers easier to use. Spacers also reduce

systemic absorption and side effects of inhaled glucocorticosteroids.

• Teach patients (and parents) how to use inhaler devices. Different

devices need different inhalation techniques. 

– Give demonstrations and illustrated instructions.

– Ask patients to show their technique at every visit. 

• For each patient, select the most appropriate device. In general:

– Children younger than 4 years of age should use a pMDI plus a

spacer with face mask, or a nebulizer with face mask.

– Children aged 4-6 years should use a pMDI plus a spacer with

mouthpiece or, if necessary, a nebulizer with face mask.

– For patients using spacers, the spacer must fit the inhaler. 

The size of the spacer must increase as a child grows and lung 

size increases.

– Patients of any age over 6 years who have difficulty using pMDIs

should use a pMDI with a spacer, a breath-actuated inhaler, a dry

powder inhaler, or a nebulizer. Dry powder inhalers require an

inspiratory effort that may be difficult to achieve during severe

attacks and for children under the age of 6 years.

– Patients who are having severe attacks should use a pMDI with a

spacer or a nebulizer. 

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Figure 6: Glossary of Asthma Medications - Controller Medications

Name and Also

Known As

Glucocorticosteroids

Adrenocorticoids

Corticosteroids

Glucocorticoids

Inhaled:

Beclomethasone

Budesonide

Flunisolide

Fluticasone

Triamcinolone

Tablets or syrups:

hydrocortisone

methylprednisolone

prednisolone

prednisone

Sodium 

cromoglycate

cromolyn

cromones

Nedocromil

cromones

Long-acting 

2-agonists

beta-adrenergis

sympathomimetics

Inhaled:

Formoterol (F)

Salmeterol (Sm)

Sustained-release

Tablets:

Salbutamol (S)

Terbutaline (T)

Sustained-release

Theophylline

Aminophylline

Methylxanthine

Usual Doses

Inhaled: Beginning

dose dependent on

asthma severity (Fig.

7 & 8) then titrated

down over 2-3

months to lowest

effective dose once

control is achieved.

Tablets or syrups:

For daily control 

use lowest effective

dose 5-40 mg of

prednisone equivalent in a.m. or qod.

For acute attacks 

40-60 mg daily in 

1 or 2 divided doses

for adults or 1-2

mg/kg daily in 

children.

MDI 2 mg or 5 mg 

2-4 inhalations 3-4

times daily. Nebuliser

20 mg 3-4 times

daily.

MDI 2 mg/puff 2-4

inhalations 2-4 times

daily.

Inhaled:

DPI -F: 1 inhalation

(12 g) bid.

MDI- F: 2 puffs bid.

DPI-Sm: 1 inhalation

(50 g) bid. 

MDI-Sm: 2 puffs bid.

Tablets:

S: 4 mg q12h.

T: 10mg q12h.

Starting dose 10

mg/kg/day with

usual 800 mg 

maximum in 1-2

divided doses.

Side Effects

Inhaled: High daily doses

may be associated with skin

thinning and bruises, and

rarely adrenal suppression.

Local side effects are 

hoarseness and oropharyngeal candidiasis. Medium

and high doses have 

produced minor growth

delay or suppression (av.

1cm) in children. Attainment

of predicted adult height

does not appear to be

affected.

Tablets or syrups: Used

long term, may lead to

osteoporosis, hypertension,

diabetes, cataracts, adrenal

suppression, growth 

suppression, obesity, skin

thinning or muscle weakness. Consider coexisting

conditions that could be

worsened by oral glucocorticosteroids, e.g. herpes virus

infections, Varicella, tuberculosis, hypertension.

Minimal side effects. Cough

may occur upon inhalation.

Cough may occur upon

inhalation.

Inhaled: fewer, and less 

significant, side effects than

tablets.

Tablets: may cause 

tachycardia, anxiety, skeletal

muscle tremor, headache,

hypokalemia.

Nausea and vomiting are

most common. Serious effects

occurring at higher serum

concentrations include

seizures, tachycardia, and

arrhythmias.

Comments

Inhaled: Potential but small

risk of side effects is well 

balanced by efficacy.

Spacer devices with MDIs

and mouth washing with

DPIs after inhalation

decrease oral Candidiasis.

Preparations not equivalent

on per puff or g basis 

(see figure 7).

Tablet or syrup: Long term

use: alternate day a.m. 

dosing produces less toxicity.

Short term: 3-10 day

"bursts" are effective for

gaining prompt control.

May take 4-6 weeks to 

determine maximum effects.

Frequent daily dosing

required.

Some patients unable to 

tolerate the taste.

Inhaled: Always use as

adjunct to anti-inflammatory

therapy. Combined with lowmedium doses of inhaledglucocorticosteroid is more

effective than increasing 

the dose of inhaledglucocorticosteroids.

Tablets: As effective as 

sustained-release theophylline.

No data for use as adjunctive

therapy with inhaledglucocorticosteroids.

Theophylline level monitoring

isoften required. Absorption

and metabolism may be

affected by many factors,

including febrile illness.

Table continued...

17

GINA POCKET GUIDE NEWfinal 4/3/03 12:13 PM Page 17
Figure 6: Glossary of Asthma Medications - Controller Medications (continued...)

Name and Also

Known As

Antileukotrienes

Leukotriene modifiers

Montelukast (M)

Pranlukast (P)

Zafirlukast (Z)

Zileuton (Zi)

Usual Doses

Adults: M 10mg qhs

P 450mg bid 

Z 20mg bid;

Zi 600mg qid.

Children: M 5 mg

qhs (6-14 y)

M 4 mg qhs (2-5 y)

Z 10mg bid (7-11 y).

Side Effects

Data are limited; no 

specific adverse effects to

date at recommended doses.

Elevation of liver enzymes

with Z and Zi and limited

case reports of reversible

hepatitis and hyperbilirubinemia with Zi.

Comments

The position of antileukotrienes in asthma 

therapy is not fully established. They provide additive

benefit when added to

inhaled glucocorticosteroids

though not as effective 

as inhaled long-acting 

2-agonists.

Figure 6: Glossary of Asthma Medications - Reliever Medications

Name and Also

Known As

Short-acting

2-agonists

adrenergics

2-stimulants

Sympathomimetics

Albuterol

Bitolterol

Fenoterol

Isoetharine

Metaproterenol

Pirbuterol

Salbutamol

Terbutaline

Anticholinergics

Ipratropium 

bromide (IB)

Oxitropium

bromide

Short-acting

theophylline

Aminophylline

Epinephrine/

adrenaline

injection

Usual Doses

Differences in potency exist but all products are essentially

comparable on a

per puff basis. For

prn symptomatic use

and pretreatment

before exercise 2

puffs MDI or 1

inhalation DPI. For

asthma attacks 4-8

puffs q2-4h, may

administer q20min 

x 3 with medical

supervision or the

equivalent of 5 mg

salbutamol by 

nebulizer.

IB-MDI 4-6 puffs q6h

or q20 min in the

emergency department. Nebuliser 500

mcg q20min x 3

then q2-4hrs for

adults and 250g

for children.

7 mg/kg loading

dose over 20 min 

followed by 0.4

mg/kg/hr continuous

infusion.

1:1000 solution

(1mg/mL) .01mg/kg

up to 0.3-0.5 mg,

can give q20min x 3. 

Side Effects

Inhaled: tachycardia, 

skeletal muscle tremor,

headache, and irritability. 

At very high dose hyperglycemia, hypokalemia.

Systemic administration as

Tablets or Syrup increases

the risk of these side effects.

Minimal mouth dryness or

bad taste in the mouth.

Nausea, vomiting, headache.

At higher serum concentrations: seizures, tachycardia,

and arrhythmias.

Similar, but more significant

effects than selective 

2-agonist. In addition: 

hypertension, fever, vomiting

in children and hallucinations.

Comments

Drug of choice for acute

bronchospasm. Inhaled route

has faster onset and is more

effective than tablet or syrup.

Increasing use, lack of

expected effect, or use of 

> 1 canister a month indicate

poor asthma control; adjust

long-term therapy accordingly. Use of ≥ 2 canisters

per month is associated with

an increased risk of a severe,

life-threatening asthma

attack.

May provide additive effects

to 2-agonist but has slower

onset of action. Is an alternative for patients with intolerance for 2-agonists.

Theophylline level monitoring

is required. Obtain serum

levels 12 and 24 hours into

infusion. Maintain between

10-15 mcg/mL.

In general, not recommended

for treating asthma attacks if

selective 2-agonists are

available.

18

GINA POCKET GUIDE NEWfinal 4/3/03 12:13 PM Page 18
19

Figure 7: Estimated Comparative Daily Dosages for 

Inhaled Glucocorticosteroids1

1 From National Asthma Education and Prevention Program, Updated 2002. NIH Publication No. 02-5075.

Web: http://www.nhlbi.nih.gov

2 Check g/puff in preparation available locally.

Drug2

Beclomethasone-CFC

42 or 84 g/puff

Beclomethasone-HFA

40 or 80 g/puff

Budesonide-DPI

200 g/inhalation

Budesonide-Neb

Inhalation suspension

Flunisolide

250 g/puff

Fluticasone

MDI: 44, 110 or 200

g/puff

DPI: 50, 100 or 250

g/inhalation

Triamcinolone 

acetonide

100 g/puff

Low Daily Dose (g)

Adult Child

168-504 84-336

80-320 80-160

200-600 100-400

- - 500

500-1000 500-750

88-264 88-176

400-1000 400-800

Medium Daily Dose (g)

Adult Child

504-840 336-672

240-480 160-320

600-1200 400-800

- - 1000

1000-2000 1000-1250

264-660 176-440

1000-2000 800-1200

High Daily Dose (g) 

Adult Child

>840 >672

>480 >320

>1200 >800

- - 2000

>2000 >1250

>660 >440

>2000 >1200

GINA POCKET GUIDE NEWfinal 4/3/03 12:13 PM Page 19
Stepwise Approach to Long-Term 

Management of Asthma

Figure 8 presents the stepwise approach to therapy to achieve and maintain

control of asthma in adults. The step system for classifying asthma severity

(Figure 3) takes into account the treatment that the patient is currently

receiving.

Figure 8: Recommended Medications by Level of Severity: 

Adults and Children Older Than 5 Years of Age

All Levels: In addition to regular daily controller therapy, rapid-acting inhaled 2-agonist1 should

be taken as needed to relieve symptoms, but should not be taken more than 3-4 times a day.

Patient education is essential at every step.

All steps: Once control of asthma is achieved and maintained for at least 3 months, a gradual

reduction of the maintenance therapy should be tried to identify the minimum therapy required to

maintain control.

1

Other options for reliever medications are (in increasing order of cost): short-acting theophylline,

inhaled anticholinergic, and short-acting oral 2-agonist. 2

See Figure 7: Estimated Equipotent Doses of Inhaled glucocorticosteroids

3

Other treatment options listed in order of increasing cost. Relative medication costs may vary from

country to country.

4

Patients with intermittent asthma but severe exacerbations should be treated as having moderate

persistent asthma.

Level of 

Severity

STEP 1

Intermittent4

STEP 2

Mild Persistent

STEP 3

Moderate

Persistent

STEP 4

Severe

Persistent

Daily Controller Medications2

• None necessary.

• Low-dose inhaled

glucocorticosteroid

• Low-to medium-dose

glucocorticosteroid plus

long-acting inhaled 2-agonist

• High-dose inhaled

glucocorticosteroid plus

long-acting inhaled 2-agonist, plus

one or more of the following if

needed: 

• Sustained-release theophylline 

• Leukotriene modifier 

• Long-acting oral 2-agonist 

• Oral glucocorticosteroid

Other Treatment Options3

• Sustained-release theophylline or

• Cromone or

• Leukotriene modifier

• Medium-dose inhaled 

glucocorticosteroid plus sustainedrelease theophylline, or

• Medium-dose inhaled 

glucocorticosteroid plus long-acting

oral 2-agonist, or

• High-dose inhaled 

glucocorticosteroid or

• Medium-dose inhaled 

glucocorticosteroid plus leukotriene

modifier

20

GINA POCKET GUIDE NEWfinal 4/3/03 12:13 PM Page 20
Figure 9 presents the stepwise approach to therapy to achieve and 

maintain control of asthma in children younger than 5 years of age. 

The step system for classifying asthma severity (Figure 3) takes into

account the treatment that the patient is currently receiving. 

1

See page 16 for use of delivery systems.

2

Other options for reliever medications are (in increasing order of cost): short-acting theophylline,

inhaled anticholinergic and short-acting oral 2-agonist. 

3

See Figure 7: Estimated Equipotent Doses of Inhaled Glucocorticosteroids

4

Other treatment options listed in order of increasing cost. Relative medication costs may vary from

country to country.

5

Patients with intermittent asthma but severe exacerbations should be treated as having moderate

persistent asthma.

Figure 9: Recommended Medications by Level of Severity:

Children Younger Than 5 Years of Age1

All Levels: In addition to regular daily controller therapy, rapid-acting inhaled 2-agonist2 should

be taken as needed to relieve symptoms, but should not be taken more than 3-4 times a day.

Patient education is essential at every step

All steps: Once control of asthma is achieved and maintained for at least 3 months, a gradual

reduction of the maintenance therapy should be tried to identify the minimum therapy required to

maintain control.

Level of 

Severity

STEP 1

Intermittent5

STEP 2

Mild Persistent

STEP 3

Moderate

Persistent

STEP 4

Severe

Persistent

Daily Controller Medications3

• None necessary.

• Low-dose inhaled 

glucocorticosteroid 

• Medium-dose inhaled 

glucocorticosteroid 

• High-dose inhaled 

glucocorticosteroid plus

one or more of the following, if

needed:

• Sustained-release theophylline 

• Long-acting inhaled 2-agonist 

• Leukotriene modifier 

• Oral glucocorticosteroid

Other Treatment Options4

• Sustained-release theophylline, or

• Cromone, or

• Leukotriene modifier

• Medium-dose inhaled 

glucocorticosteroid plus sustainedrelease theophylline, or

• Medium-dose inhaled 

glucocorticosteroid plus long-acting

inhaled 2-agonist, or

• High-dose inhaled glucocorticosteroid or

• Medium-dose glucocorticosteroid

plus leukotriene modifier

21

GINA POCKET GUIDE NEWfinal 4/3/03 12:13 PM Page 21
Part 5: Establish Individual Plans To Manage Asthma

Attacks

Exacerbations of asthma (asthma attacks) are episodes of a progressive

increase in shortness of breath, cough, wheezing, or chest tightness, or a

combination of these symptoms. 

■ Do not underestimate the severity of an attack; severe asthma attack

may be life threatening. (Figure 10)

■ Patients at high risk for asthma-related death include those with:

• History of near-fatal asthma.

• Hospitalization or emergency visit for asthma within the past year,

or prior intubation for asthma.

• Current use of, or recent withdrawal from, oral glucocorticosteroids.

• Over-dependence on rapid-acting inhaled 2-agonists.

• History of psychosocial problems or denial of asthma or its severity.

• History of noncompliance with asthma medication plan.

■ Patients should immediately seek medical care if...

• The attack is severe:

– The patient is breathless at rest, is hunched forward, talks in

words rather than sentences (infant stops feeding), agitated,

drowsy or confused, has bradycardia, or a respiratory rate

greater than 30 per minute.

– Wheeze is loud or absent.

– Pulse is greater than 120/min (greater than 160/min for infants).

– PEF is less than 60 percent of predicted or personal best

even after initial treatment.

– The patient is exhausted.

• The response to the initial bronchodilator treatment is

not prompt and sustained for at least 3 hours.

• There is no improvement within 2 to 6 hours after oral 

glucocorticosteroid treatment is started.

• There is further deterioration.

■ Asthma attacks require prompt treatment:

• Inhaled rapid-acting 2-agonists in adequate doses are essential. If

inhaled medications are not available, oral bronchodilators may be

considered. 

22

GINA POCKET GUIDE NEWfinal 4/3/03 12:13 PM Page 22
• Oral glucocorticosteroids introduced early in the course of a 

moderate or severe attack help to reverse the inflammation and

speed recovery.

• Oxygen is given at health centers or hospitals if the patient is 

hypoxemic.

• Methylxanthines are not recommended if used in addition to high

doses of inhaled 2-agonist. However, theophylline can be used if

inhaled 2-agonists are not available. If the patient is already taking

theophylline on a daily basis, serum concentration should be measured before adding short-acting theophylline.

• Epinephrine (adrenaline) may be indicated for acute treatment of

anaphylaxis and angioedema.

■ Therapies not recommended for treating attacks include:

• Sedatives (strictly avoid)

• Mucolytic drugs (may worsen cough)

• Chest physical therapy/physiotherapy (may increase patient 

discomfort)

• Hydration with large volumes of fluid for adults and older children

(may be necessary for younger children and infants)

• Antibiotics (do not treat attacks but are indicated for patients who

also have pneumonia or bacterial infection such as sinusitis).

■ Mild attacks can be treated at home if the patient is prepared and has a

personal asthma management plan that includes action steps (Figure 11).

■ Moderate attacks may require, and severe attacks usually require, care

in a clinic or hospital (Figure 12).

■ Monitor Response to Treatment

Evaluate symptoms and, as much as possible, peak flow. In hospital,

also assess oxygen saturation; consider arterial blood gas measurement in

patients with suspected hypoventilation, exhaustion, severe distress, or peak

flow 30-50 percent predicted.

23

GINA POCKET GUIDE NEWfinal 4/3/03 12:13 PM Page 23
Figure 10. Severity of Asthma Attacks

Parameter1

Breathless

Talks in

Alertness

Respiratory rate

Accessory 

muscles and

suprasternal

retractions

Wheeze

Pulse/min.

PEF 

after initial 

bronchodilator

% predicted or

% personal best

PaO2 (on air)*

and/or

PaCO2*

SaO2% (on air)*

Mild

Walking

Can lie down

Sentences

May Be agitated

Increased

Usually not

Moderate, often

only end 

expiratory

< 100

Over 80%

Normal Test 

not usually 

necessary

< 45 mmHg

> 95%

Moderate

Phrases

Usually agitated

Increased 

Usually

Loud

100-120

Approximately

60-80%

> 60 mmHg 

< 45 mmHg

91-95%

Severe

Words

Usually agitated

Often > 30/min

Usually

Usually Loud

> 120

< 60% predicted

or personal best

(100 L/min

adults) or

response lasts 

< 2 hours

< 60 mmHg

Possible cyanosis

> 45 mmHg:

Possible 

respiratory 

failure 

< 90%

Respiratory

arrest 

imminent

Drowsy or 

confused

Paradoxical

Paradoxical

thoracoabdominal

movement

Absence of

wheeze

Bradycardia

Guide to rates of breathing associated with respiratory distress in awake children

Age Normal rate

< 2 months < 60/min

2-12 months < 50/min

1-5 years < 40/min

6-8 years < 30/min

Guide to limits of normal pulse rate in children:

Infants 2-12 months -Normal rate <160/min

Preschool 1-2 years -Normal rate <120/min

School age 2-8 years -Normal rate <110/min

Hypercapnia (hypoventilation) develops more readily in young children than in adults and adolescents.

1 The presence of several parameters, but not necessarily all, indicate the general classification of the attack.

* Kilopascals are also used internationally; conversion would be appropriate in this regard.

24

GINA POCKET GUIDE NEWfinal 4/3/03 12:13 PM Page 24
Figure 11. Management of an Asthma Attack: Home Treatment

Assess Severity

Cough, breathlessness, wheeze, chest tightness, use of accessory 

muscles, suprasternal retractions, and sleep disturbance. PEF less than 

80 percent of personal best or predicted.

Initial Treatment

Inhaled rapid-acting 2-agonist up to three treatments in 1 hour. 

(Patients at high risk of asthma-related death should contact physician

promptly after initial treatment.)

Response to Initial Treatment Is... 

Good if...

Symptoms subside

after initial 2-agonist

and relief is sustained

for 4 hours. 

PEF is greater than

80% predicted or

personal best.

ACTIONS:

• May continue 

2-agonist every 

3-4 hours for 1-2

days.

• Contact physician

or nurse for 

followup 

instructions.

Poor if...

Symptoms persist or

worsen despite 

initial 2-agonist

treatment.

PEF is less than 60%

predicted or 

personal best.

ACTIONS:

• Add oral 

glucocorticosteroid.

• Repeat 2-agonist

immediately.

• Add inhaled 

anticholinergic.

• Immediately 

transport to 

hospital emergency 

department.

Incomplete if...

Symptoms decrease

but return in less than

3 hours after initial

2-agonist treatment.

PEF is 60-80% 

predicted or personal

best.

ACTIONS:

• Add oral 

glucocorticosteroid. 

• Add inhaled 

anticholinergic. 

•Continue 2-agonist.

• Consult clinician

urgently for 

instructions.

25

GINA POCKET GUIDE NEWfinal 4/3/03 12:13 PM Page 25
Figure 12. Management of Asthma Attacks: Hospital-Based Care

Initial Assessment

• History, physical examination (auscultation, use of accessory muscles, heart rate, respiratory rate, PEF or

FEV1, oxygen saturation, arterial blood gas of patient in extremis, and other tests as indicated)

Initial Treatment

• Inhaled rapid-acting 2-agonist, usually by nebulization, one dose every 20 minutes for 1 hour

• Oxygen to achieve O2 saturation ≥ 90% (95% children)

• Systemic glucocorticosteroids if no immediate response, or if patient recently took oral 

glucocorticosteroids, or if episode is severe

• Sedation is contraindicated in the treatment of attacks

Repeat Assessment

Physical Exam, PEF or FEV1, O2 saturation, other tests as needed

Moderate Episode

• PEF 60-80% predicted/

personal best

• Physical exam: moderate 

symptoms, accessory muscle use

• Inhaled 2-agonist and inhaled

anticholinergic every 60 minutes

• Consider glucocorticosteroids

• Continue treatment 1-3 hours,

provided there is improvement

Severe Episode

• PEF < 60% predicted/personal best

• Physical exam: severe symptoms at rest, chest retraction

• History: high-risk patient

• No improvement after initial treatment

• Inhaled 2-agonist and inhaled anticholinergic

• Oxygen

• Systemic glucocorticosteroid

• Consider subcutaneous, intramuscular, or intravenous 2-agonist

• Consider intravenous methylxanthines

• Consider intravenous magnesium

Good Response

• Response sustained 60 

minutes after last treatment

• Physical exam: normal

• PEF > 70%

• No distress

• O2 saturation > 90% 

(95% children)

Incomplete Response

Within1-2 Hours

• History: high-risk patient

• Physical exam: mild to 

moderate symptoms

• PEF < 70%

• O2 saturation not improving

Poor Response Within 1 Hour

• History: high-risk patient

• Physical exam: symptoms severe,

drowsiness, confusion

• PEF < 30%

• PCO2 > 45 mmHg

• PO2 < 60 mmHg

Improve Not Improved

Discharge Home

• If PEF > 60% predicted/ personal best and 

sustained on oral/inhaled medications

Admit to Intensive Care

• If no improvement within 6-12 hours

Discharge Home

• Continue treatment with

inhaled 2-agonist

• Consider, in most cases, oral

glucocorticosteroid

• Patient education:

Take medicine correctly

Review action plan

Close medical followup

Admit to Hospital

• Inhaled 2-agonist ± inhaled

anticholinergic

• Systemic glucocorticosteroid

• Oxygen

• Consider intravenousm

ethylxanthines

• Monitor PEF, O2 saturation,

pulse, theophylline

Admit to Intensive Care

• Inhaled 2-agonist + anticholinergic

• Intravenous glucocorticosteroid

• Consider subcutaneous, 

intramuscular, or intravenous

2-agonists

• Oxygen

• Consider intravenous 

methylxanthines

• Possible intubation and

mechanical ventilation

Note: Preferred treatments are inhaled 2-agonists in high doses and glucocorticosteroids. If inhaled 2-agonists are not 

available, methylxanthines may be considered.

26

GINA POCKET GUIDE NEWfinal 4/3/03 12:13 PM Page 26
Part 6: Provide Regular Followup Care

Patients with asthma need regular supervision and support by a health 

care professional who is knowledgeable about the condition. Continual

monitoring is essential to assure that therapeutic goals are met.

Once asthma control is established, regular followup visits, at 1- to 

6-month intervals as appropriate, continue to be essential. During these

visits, monitor and review treatment plans, medications, and level of asthma

control. 

SPECIAL CONSIDERATIONS ARE REQUIRED IN 

MANAGING ASTHMA IN RELATION TO:

• Pregnancy

• Surgery

• Physical activity

• Rhinitis

• Sinusitis and nasal polyps

• Occupational asthma

• Respiratory infections

• Gastroesophageal reflux

• Aspirin-induced asthma

27

Discrimination Prohibited: Under provisions of applicable public laws enacted by Congress since 1964,

no person in the United States shall, on the grounds of race, color, national origin, handicap, or age, 

be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any

program or activity (or, on the basis of sex, with respect to any education program or activity) receiving

Federal financial assistance. In addition, Executive Order 11141 prohibits discrimination on the basis of

age by contractors and subcontractors in the performance of Federal contracts and Executive Order

11246 states that no federally funded contractor may discriminate against any employee or applicant for

employment because of race, color, religion, sex, or national origin. Therefore, the National Heart, Lung,

and Blood Institute must be operated in compliance with these laws and Executive Orders. 

GINA POCKET GUIDE NEWfinal 4/3/03 12:13 PM Page 27
U.S. Department of Health and Human Services

Public Health Service

National Institutes of Health

National Heart, Lung, and Blood Institute

Visit the GINA web site at www.ginasthma.com

The Global Initiative for Asthma is supported by educational grants from:

YAMANOUCHI backcover REV 7/23/03 11:43 AM Page i50