Nuovo Ospedale Apuano, Massa, Italy.
Catholic University of Roma, Roma, Italy.
Ther Adv Respir Dis. 2023 Jan-Dec;17:17534666231159261. doi: 10.1177/17534666231159261.
The article traces the concept of asthma control within GINA guidelines over the past 25 years. In the first 15 years after 1995, the main objective of asthma management was to obtain the control of all clinical and functional characteristics of asthma. A landmark study (GOAL) showed for the first time that a good control of asthma is a reasonable outcome that can be achieved in a large proportion of asthmatics with a regular appropriate treatment. In the following years, more emphasis was placed on the role of exacerbations as critical manifestations of poor asthma control, whose frequency is associated with excessive FEV1 decline and increased risk of death. Accordingly, the 2014 GINA report makes a clear distinction between the control of the day-by-day symptoms and the reduction in the risk of severe exacerbations, stating that both conditions should be obtained. The 2019 update included a significant change in the management of mild asthma, prioritizing the prevention of exacerbations to that of mild symptoms. This view was repeated in the 2021 update, where the prevention of exacerbations, together with an acceptable symptom control with a minimal use of rescue medication, appeared to be the real main goal of asthma management. While a discrepancy between current symptoms and exacerbations may be present in mild asthma, a significant relationship between these two features is observed in moderate-severe asthma: a persistent poor symptom control is a major risk factor for exacerbations, whereas achieving symptom control through regular treatment is associated with a reduction in exacerbation rate. Thus, the opinion that frequent symptoms are not important in the absence of acute exacerbations should be discouraged, whereas education of patients to a good symptom perception and to improve adherence to regular treatment should be implemented. Furthermore, the persistence of risk factors, such as increased airway inflammation, even in a patient with minor daily symptoms, should be considered for optimizing treatment.
本文追溯了 GINA 指南中过去 25 年来哮喘控制概念的演变。在 1995 年后的前 15 年，哮喘管理的主要目标是获得哮喘所有临床和功能特征的控制。一项具有里程碑意义的研究（GOAL）首次表明，良好的哮喘控制是一个合理的目标，可以在很大一部分接受定期适当治疗的哮喘患者中实现。在随后的几年里，人们更加重视哮喘加重作为哮喘控制不佳的关键表现，其频率与 FEV1 过度下降和死亡风险增加有关。因此，2014 年 GINA 报告明确区分了日常症状的控制和严重哮喘加重风险的降低，指出这两种情况都应该得到控制。2019 年的更新版包括对轻度哮喘管理的重大改变，优先预防加重而不是轻度症状。这一观点在 2021 年的更新版中得到了重复，其中预防加重，加上用最小剂量急救药物即可接受的症状控制，似乎是哮喘管理的真正主要目标。虽然轻度哮喘中可能存在当前症状和加重之间的差异，但在中重度哮喘中观察到这两个特征之间存在显著的关系：持续的症状控制不佳是加重的主要危险因素，而通过定期治疗实现症状控制与降低加重率有关。因此，应该摒弃频繁症状在没有急性加重的情况下不重要的观点，而应该对患者进行教育，以提高他们对症状的感知和改善对定期治疗的依从性。此外，即使患者每日症状轻微，也应考虑持续存在的危险因素，如气道炎症增加，以优化治疗。
