Copd & Asthma in Trivendram 22 Oct 2009

8/18/2019 Copd & Asthma in Trivendram 22 Oct 2009

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E-mail: r rasad2 redifmail.com

DR. RAJENDRA PRASADMD, DTCD, FAMS, FCCP (USA), FNCCP, FCAI, FIAB, FIMSAProfessor and Head, Department of Pulmonary Med!ne,

C"S"M" Med!al Un#ersty Uttar Prades$, %u!&no' (Inda)

(rst'$le "*"Med!al Un#ersty %u!&no', Inda)

Internatonal *o#ernor, Amer!an Colle+e of C$est P$ys!ans (Nort$ Inda)

Past Presdent, Indan C$est So!ety

Past Presdent, Indan Asso!aton for Bron!$olo+y

Past Presdent, Natonal Colle+e of C$est P$ys!ans of Inda

Past Presdent, Indan Colle+e of Aller+y Ast$ma Appled Immunolo+y

Past Presdent, Indan Med!al Asso!aton (%u!&no' Bran!$)

C$arman , State Tas& For!e UP, -e#sed Natonal Tu.er!uloss Control Pro+ramme

Asthma & COPD Asthma & COPD

Management at PHCManagement at PHCLevelLevel

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What is What is

Asthma ? Asthma ?

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Definition of AsthmaDefinition of Asthma

Asthma is a chronic inflammatory disorder of the Asthma is a chronic inflammatory disorder of the

airways in which many cells and cellular elementsairways in which many cells and cellular elements

play a role. The chronic inflammation is associatedplay a role. The chronic inflammation is associated

with airway hyper responsiveness, chest tightness,with airway hyper responsiveness, chest tightness,and coughing, particularly at night or in the earlyand coughing, particularly at night or in the early

morning. These episodes are usually associatedmorning. These episodes are usually associated

with widespread, but variable, airflow obstructionwith widespread, but variable, airflow obstruction

with in the lung that is often reversible eitherwith in the lung that is often reversible eitherspontaneously or with treatment.spontaneously or with treatment.

*INA / 0112

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Mechanisms Underlying theMechanisms Underlying the

Definition of AsthmaDefinition of Asthma

Risk actorsRisk actors!for development of asthma"!for development of asthma"

FLAMMAT O

FLAMMAT O

Airway Airway

#yperresponsiveness#yperresponsiveness Airflow $bstruction Airflow $bstruction

Risk actorsRisk actors!for e%acerbations"!for e%acerbations"

SymptomsSymptoms

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What is the BurdenWhat is the Burdenof Asthma ?of Asthma ?

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1% to 18% of the population in dierent countries.1% to 18% of the population in dierent countries.

250,000 deaths annually.250,000 deaths annually.

15 to 20 million persons with asthma in n!ia15 to 20 million persons with asthma in n!ia

15 million A!"s lost annually due to Asthma15 million A!"s lost annually due to Asthmarepresentin# 1% of total #lo$al disease $urden.representin# 1% of total #lo$al disease $urden.

a&or factors contri$utin# to asthma mor$iditya&or factors contri$utin# to asthma mor$idity

and mortality areand mortality are "n!er !iagnosis"n!er !iagnosis ''inappropriateinappropriate treatmenttreatment

$ '(()*+A *uidelines '((-

Burden Of Asthma

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Prevalen#e an! ris$ %a#tors %orPrevalen#e an! ris$ %a#tors %orron#hial asthma in n!ian a!"lts' Aron#hial asthma in n!ian a!"lts' A

m"lti#entre st"!( m"lti#entre st"!( ()*05 su$&ects +)(*82 men, )52) -omen -ere()*05 su$&ects +)(*82 men, )52) -omen -ere

analy/ed.analy/ed. ne or more respiratory symptoms -ere presentne or more respiratory symptoms -ere present

in .)10.5% su$&ects.in .)10.5% su$&ects.

o3erall pre3alence of asthma is 2.)8%.o3erall pre3alence of asthma is 2.)8%. 4re3alence in male and female is 2.21% and4re3alence in male and female is 2.21% and

2.5*%.2.5*%. 4re3alence in rural and ur$an is 2.18% and 2.55%.4re3alence in rural and ur$an is 2.18% and 2.55%. emale se6, ad3ancin# a#e, usual residence inemale se6, ad3ancin# a#e, usual residence in

ur$an area, lo-er socioeconomic status, history ofur$an area, lo-er socioeconomic status, history ofatopy, history of asthma in a 7rst de#ree relati3e,atopy, history of asthma in a 7rst de#ree relati3e,and all forms of to$acco smoin# -ere associatedand all forms of to$acco smoin# -ere associated-ith hi#her odd ratio.-ith hi#her odd ratio.

A N Agarwal etal IJCD 2006;48:13-22A N Agarwal etal IJCD 2006;48:13-22


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What are the 9isWhat are the 9isactors ?actors ?

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Risk actors for AsthmaRisk actors for Asthma

#ost actors#ost actors *enetic eg.*enetic eg.

*enes predisposing to atopy*enes predisposing to atopy *enes predisposing to airway*enes predisposing to airway

hyper responsivenesshyper responsiveness $besity$besity *ender *ender

/nvironmental actors Allergens

+ndoor0 Domestic mites,

furred animal, 1ockroach,

fungi, mold, yeasts.

$utdoor0 2ollens, fungi, molds,yeasts.

+nfections !2redominately viral"$ccupational sensiti3ersTobacco 4moke

2assive 4moking Active smoking

$utdoor5+ndoor Air pollutionDiet

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)riggers o% asthma)riggers o% asthma

9espiratory infections +usually 3iral9espiratory infections +usually 3iral Aller#ens +indoor:outdoor Aller#ens +indoor:outdoor Air pollution +indoor:outdoor includin# Air pollution +indoor:outdoor includin#

smoe and fumes +$iomass fuelsmoe and fumes +$iomass fuel ;o$acco smoe +acti3e and passi3e;o$acco smoe +acti3e and passi3e ru#s Beta$locers and sru#s Beta$locers and s

+paracetamol and nimesulide are safe+paracetamol and nimesulide are safe Additi3es and preser3ati3es Additi3es and preser3ati3es old e6posure e6ercise, psycholo#ical orold e6posure e6ercise, psycholo#ical or

other unaccustomed stressother unaccustomed stress

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Objective measurements

•>20% diurnal variation on ≥3 days ina week for 2 weeks on PEF diary

•or FEV1 ≥15% (and 200ml in!rease afters"ort a!tin# $

2 a#onist or steroid talets

•or FEV1 ≥15% de!rease after & min ofe'er!ise

•"istamine or met"a!"oline !"allen#e

Signs

•none (common)

•w"eee ) di*use+ ilateral+e',iratory (± ins,iratory

• ta!"y,nea

Helpful additional information

•,ersonal-family "istory of ast"ma• re!o#nised tri##ers•,attern and severity of sym,toms and

e'a!erations•"istory of worsenin# after

as,irin-./- β lo!ker use

Smptoms!episodic"variable#

•w"eee•s"ortness of reat"•!"est ti#"tness•!ou#"

$onsider diagnosis of ast%ma

in patients &it% some or all

of t%ese features

Diagnosis of Ast%ma

spirometry is not mandatory in te diagnosti! wor"#$ %#t so#ld %e

$er&ormed in sit#ations were te !lini!al data is oterwise e'#i(o!al

spirometry is not mandatory in te diagnosti! wor"#$ %#t so#ld %e

$er&ormed in sit#ations were te !lini!al data is oterwise e'#i(o!al

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Pea$ *ow meter Pea$ *ow meter

Widely a3aila$le and simple.Widely a3aila$le and simple. @i#h de#ree of 3aria$ility@i#h de#ree of 3aria$ility lac of reproduci$ility.lac of reproduci$ility.

9educed 4 is hi#hly su##esti3e $ut not9educed 4 is hi#hly su##esti3e $ut notdia#nostic.dia#nostic. >n the a$sence of spirometry, a reduced 4>n the a$sence of spirometry, a reduced 4

can $e used as a surro#ate to dia#nosecan $e used as a surro#ate to dia#noseairCo- limitation.airCo- limitation.

=imilarly, an increase in 4 of 20% or more=imilarly, an increase in 4 of 20% or moreafter $ronchodilator administration -ith atafter $ronchodilator administration -ith atleast *0 !:min a$solute increment, can $eleast *0 !:min a$solute increment, can $econsidered as $ein# only a supporti3econsidered as $ein# only a supporti3e

e3idence to-ards presence of $ronchodilatore3idence to-ards presence of $ronchodilator

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1lassification of 4everity1lassification of 4everity

CLASSIFY SEVERITYCLASSIFY SEVERITYClinical Features Before TreatmentClinical Features Before Treatment

SymptomsSymptomsNocturnalNocturnalSymptomsSymptoms FEVFEV or !EFor !EF

STE! "STE! "

Se#ereSe#ere!ersistent!ersistent

STE! $STE! $

%o&erate%o&erate!ersistent!ersistent

STE! 'STE! '

%il&%il&!ersistent!ersistent

STE! STE!

IntermittentIntermittent

ContinuousContinuous

Limite& physicalLimite& physicalacti#ityacti#ity

DailyDaily

Attac(s affect acti#ityAttac(s affect acti#ity

) time a *ee() time a *ee(

+ut , time a &ay +ut , time a &ay

, time a *ee(, time a *ee(

AsymptomaticAsymptomatic

an& normal !EFan& normal !EF

+et*een attac(s+et*een attac(s

Fre-uentFre-uent

) time *ee() time *ee(

) ' times a month) ' times a month

≤

' times a month' times a month

≤ ./0 pre&icte&./0 pre&icte&

Varia+ility ) $/0Varia+ility ) $/0

./ 1 2/0 pre&icte&./ 1 2/0 pre&icte&

Varia+ility ) $/0Varia+ility ) $/0

≥ 2/0 pre&icte&2/0 pre&icte&

Varia+ility '/ 1 $/0Varia+ility '/ 1 $/0

≥

2/0 pre&icte&2/0 pre&icte&

Varia+ility , '/0Varia+ility , '/0

The presence of one feature of se#erity is sufficient to place patient in that cate3oryThe presence of one feature of se#erity is sufficient to place patient in that cate3ory44The presence of one feature of se#erity is sufficient to place patient in that cate3oryThe presence of one feature of se#erity is sufficient to place patient in that cate3ory44

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+everit( o% Asthma+everit( o% Asthma

ildild oderatoderatee

=e3ere=e3ere

=ymptoms distur$in#=ymptoms distur$in#

sleepsleep

D1:- D1:- E1:- E1:- ailyaily

aytime symptomsaytime symptoms DailyDaily ailyaily ailyaily

!imitation of!imitation ofaccustomed acti3itiesaccustomed acti3ities


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How )o )reatHow )o )reat ??

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,oals o% )reatment,oals o% )reatment

inimal +ideally none symptoms durin# dayinimal +ideally none symptoms durin# dayand ni#ht.and ni#ht.

inimal +ideally none symptoms durin#inimal +ideally none symptoms durin#e6ercise.e6ercise.

inimal need for relie3er medications.inimal need for relie3er medications.


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FI3 INT--%ATD C4MP4NNTS4F ASTHMA MANA*MNTASTHMA MANA*MNT

1-1- Develop Patient.Do#torDevelop Patient.Do#tor

PartnershipPartnership

2.2. >dentify and 9educe 6posure to>dentify and 9educe 6posure to

9is actors9is actors

).). Assess, ;reat, and onitor Asthma Assess, ;reat, and onitor Asthma.. ana#e Asthma 6acer$ationsana#e Asthma 6acer$ations

5.5. =pecial onsiderations.=pecial onsiderations.

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Asthma %ana3ement

Patents5Do!tor Partners$p

Contin#o#s $ro!ess wi! $ro(ide te $atient )

&amily s#ita%le in&ormation and training so tat te

$atient !an "ee$ well and ad*#st treatment a!!ording

to medi!ation $lan de(elo$ed in ad(an!e wit ealt!are $ro&essional+

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Asthma %ana3ement

Patents du!aton

A(oid ris" &a!tors

,a"e medi!ation !orre!tly

nderstand te di&&eren!e %etween .!ontroller/ and

.relie(er/ medi!ations+

onitor teir stat#s #sing sym$toms and i& a(aila%le

5e!ognie signs tat astma is worsening and ta"e a!tion+

7ee" medi!al el$ as a$$ro$riate

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.4E 6/7E 89 P:E.:.4E 6/7E 89 P:E.:

Not usn+ (n678)

In!orre!t29"0:

82";2:

Corre!t ;1"2:

Usn+ (n6;10)

- Prasad et al" Indan < Aller+y ast$ma Immunolo+y 0110= ;7> 29/90- Prasad et al" Indan < Aller+y ast$ma Immunolo+y 0110= ;7> 29/90- Prasad et al" Indan < Aller+y ast$ma Immunolo+y 0110= ;7> 29/90- Prasad et al" Indan < Aller+y ast$ma Immunolo+y 0110= ;7> 29/90

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.4E :E;. 29/90- Prasad et al" Indan < Aller+y ast$ma Immunolo+y 0110= ;7> 29/90- Prasad et al" Indan < Aller+y ast$ma Immunolo+y 0110= ;7> 29/90- Prasad et al" Indan < Aller+y ast$ma Immunolo+y 0110= ;7> 29/90

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1.1. e3elop 4atient:octor 4artnershipe3elop 4atient:octor 4artnership

2-2- !enti%( an! /e!"#e pos"re to!enti%( an! /e!"#e pos"re to

/is$ a#tors/is$ a#tors

).). Assess, ;reat, and onitor Asthma Assess, ;reat, and onitor Asthma

.. ana#e Asthma 6acer$ationsana#e Asthma 6acer$ations


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Component 2' !enti%( an!Component 2' !enti%( an!

/e!"#e pos"re to /is$/e!"#e pos"re to /is$

a#torsa#tors

%etho&s to pre#ent onset of asthma are not yet a#aila+le%etho&s to pre#ent onset of asthma are not yet a#aila+le

+ut this remains an important 3oal+ut this remains an important 3oal

%easures to re&uce e5posure to causes of asthma%easures to re&uce e5posure to causes of asthmae5acer+ations 6e5acer+ations 6e.g.e.g. aller3ens7 pollutants7 foo&s an&aller3ens7 pollutants7 foo&s an&

me&ications8 shoul& +e implemente& *hene#er possi+leme&ications8 shoul& +e implemente& *hene#er possi+le

Re&uce e5posure to in&oor aller3ensRe&uce e5posure to in&oor aller3ens

A#oi& to+acco smo(eA#oi& to+acco smo(e

A#oi& #ehicle emissionA#oi& #ehicle emission

I&entify irritants in the *or(placeI&entify irritants in the *or(place

E5plore role of infections on asthma &e#elopment7 especiallyE5plore role of infections on asthma &e#elopment7 especiallyin chil&ren an& youn3 infantsin chil&ren an& youn3 infants

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1.1. e3elop 4atient:octor 4artnershipe3elop 4atient:octor 4artnership

2.2. >dentify and 9educe 6posure to>dentify and 9educe 6posure to

9is actors9is actors

3-3- Assess4 )reat4 an! Monitor Assess4 )reat4 an! Monitor

Asthma Asthma.. ana#e Asthma 6acer$ationsana#e Asthma 6acer$ations


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2art )0 6ongterm Asthma Management

2harmacologic Therapy

Controller %e&ications9

Inaled and systemi!

gl#!o!orti!osteroids e#"otriene modi&ier

ong-a!ting inaled 92-agonists in

!omo%ination wit inaledgl#!o!orti!osteroids

7#stained release teo$ylline Cromones

Anti Ig

ter systemi! steroid s$aring tera$y

Relie#er %e&ications9

5a$id-a!ting inaled 92-agonists

Inaled anti!olinergi!s

7ort-a!ting oral teo$ylline

7ort-a!ting oral 92-agonists

*INA /0112*INA /0112

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.4E 67/ PE/;8E 89.4E 67/ PE/;8E 89

AE;4 P;::.E/ (.?3B0AE;4 P;::.E/ (.?3B0

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What should $e 9outeWhat should $e 9oute

of Administration ofof Administration ofru#s ?ru#s ?

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-4UT 4F ADMINIST-ATI4N


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INHA%D 3S 4-A% -4UT

In$aled 4ral

Dose ow @ig

7$eed o& onset 5a$id 7low

7ide e&&e!ts 5are Common

Administration 5e'#+ instr#!tion asy

engt o& a!tion 4 -12 o#rs 4 -18 o#rs7ite o& a!tion o!al 7ystemi!

re(ention o& eer!ise Bood oor

ind#!ed astma


2harmacologic Therapy

asad ucknow

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A!vantages o% spa#er A!vantages o% spa#er

"sage"sage 3ercomes coordination pro$lems3ercomes coordination pro$lems =electi3e remo3al of non respira$le particles due to a=electi3e remo3al of non respira$le particles due to a

reduction in the initial for-ard 3elocity, and partialreduction in the initial for-ard 3elocity, and partiale3aporation of the propellante3aporation of the propellant

ecreases the amount of dru# deposited in theecreases the amount of dru# deposited in theoropharyn6. ;his reducesoropharyn6. ;his reduces locallocal as -ell asas -ell as systemicsystemic sidesideeectseects

ecreases cold freon eectecreases cold freon eect >ncreases dru# deposition in lun#s>ncreases dru# deposition in lun#s

=peci7cally recommended in=peci7cally recommended in 4ro$lems -ith coordination4ro$lems -ith coordination hildrenhildren @i#h dose inhaled steroids+E800 mc#:day@i#h dose inhaled steroids+E800 mc#:day Acute asthma usin# hi#h dose $ronchodilators Acute asthma usin# hi#h dose $ronchodilators

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Which de3ice toWhich de3ice to

use ?use ?

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CH4IC 4F INHA%- F4- CHI%D-N Age Group Preferred Device Alternative Devic

4 yrs+ DI 7$a!er Ne%#lier wit

wit &a!e mas" &a!e mas"

4 - 6 yrs+ DI 7$a!er Ne%#lier witwit mo#t $ie!e &a!e mas"

E 6 yrs+ DI Ne%#lier witor mo#t $ie!e

%reat a!ti(ated DI or

DI wit s$a!ers

Esta+lish %e&ication !lans for Lon31TermEsta+lish %e&ication !lans for Lon31Term

Asthma %ana3ement in Infants an& Chil&renAsthma %ana3ement in Infants an& Chil&ren

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2art )0 6ongterm Asthma Management2art )0 6ongterm Asthma Management

4tepwise Approach to Asthma Therapy Adults4tepwise Approach to Asthma Therapy Adults

Relie#er9Relie#er9 Rapi&1actin3 inhale& :Rapi&1actin3 inhale& :''1a3onist prn1a3onist prn

Controller9Controller9 Daily inhaledDaily inhaled

corticosteroidcorticosteroid

Controller9Controller9 Daily inhaledDaily inhaledcorticosteroidcorticosteroid Daily longDaily longacting inhaledacting inhaled

77''agonistagonist

Controller9Controller9

Daily inhaledDaily inhaledcorticosteroidcorticosteroid Daily long 8Daily long 8acting inhaledacting inhaled

77''agonistagonist

plus plus !if needed"!if needed"

&hen&henasthma isasthma iscontrolled,controlled,

reducereducetherapytherapy

Monitor Monitor

STE! 9STE! 9

IntermittentIntermittent

STE! '9STE! '9

%il& !ersistent%il& !ersistent

STE! $9STE! $9 %o&erate%o&erate!ersistent!ersistent

STE! "9STE! "9Se#ereSe#ere

!ersistent!ersistent

STE! Do*nSTE! Do*n

;utcome9 Asthma Control;utcome9 Asthma Control ;utcome9 Best;utcome9 Best !ossi+le Results!ossi+le Results

Alternative controller and reliever medications may be considered !see te%t". Alternative controller and reliever medications may be considered !see te%t".

Controller9Controller9

oneone Theophylline TheophyllineSR SR

6eukotriene 6eukotriene

6ongacting oral 6ongacting oral

77'' agonist agonist

$ral corticosteroid $ral corticosteroid

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Management o% asthma inManagement o% asthma in

!i6erent stages!i6erent stages

=ta#in=ta#in##

aily controlleraily controlleredicationedication

therthertreatmentstreatments

ildild !o-dose >=!o-dose >= =ustainedrelease=ustainedreleasetheophylline ortheophylline orromonesromones

oderoderateate

oderate dose >= Hoderate dose >= Hinhaled !ABA and:or !;9Ainhaled !ABA and:or !;9A

oderate dose >=oderate dose >=H either sustainedH either sustainedreleasereleasetheophylline ortheophylline or!;9A or oral !ABA!;9A or oral !ABA

@i#hdose >= @i#hdose >=

=e3ere=e3ere @i#h dose >= H inhaled !ABA@i#h dose >= H inhaled !ABAplus one or more of theplus one or more of the

follo-in# if neededI sustainedfollo-in# if neededI sustainedrelease theophylline,release theophylline,

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+tepping !own+tepping !own

treatmenttreatmentWhere control is achie3ed -ith hi#h orWhere control is achie3ed -ith hi#h or

medium dose >nhaledmedium dose >nhaled

#lucocorticosteroids alone#lucocorticosteroids alone 50% reduction in dose should $e attempted50% reduction in dose should $e attempted

at ) month inter3als.at ) month inter3als.

Where control is achie3ed at a lo- doseWhere control is achie3ed at a lo- dose

of >nhaled #lucocorticosteroids aloneof >nhaled #lucocorticosteroids alone =-itched to once daily dosin#=-itched to once daily dosin#..

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treatmenttreatment #ont!-#ont!-

Where control is achie3ed -ith com$ination ofWhere control is achie3ed -ith com$ination of

inhaled #lucocorticosteroids and lon# actin#inhaled #lucocorticosteroids and lon# actin# JJ22a#oinst.a#oinst. 50% reduction in inhaled #lucocorticosteroids -hile50% reduction in inhaled #lucocorticosteroids -hile

continuin# the lon# actin#continuin# the lon# actin# JJ22a#oinst.a#oinst. >f control>f controlmaintained further reduction in >= till lo- dose >=maintained further reduction in >= till lo- dose >=

reached, then lon# actin#reached, then lon# actin# JJ22a#oinst may $e stopped.a#oinst may $e stopped.9 9

An alternati3e is to s-itch com$ination to once daily An alternati3e is to s-itch com$ination to once dailydosin#.dosin#.

9 9

Another alternati3e to discontinue the lon# actin# Another alternati3e to discontinue the lon# actin# JJ22a#oinst at an earlier sta#e and continue >=a#oinst at an earlier sta#e and continue >=monotherapy at the same dose in the com$inationmonotherapy at the same dose in the com$inationinhaler.inhaler.

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treatmenttreatment #ont!-#ont!-Where control is achie3ed -ithWhere control is achie3ed -ith

com$ination of inhaledcom$ination of inhaled

#lucocorticosteroids and controllers#lucocorticosteroids and controllersother than lon# actin#other than lon# actin# JJ22a#oinst.a#oinst. 50% reduction in inhaled50% reduction in inhaled

#lucocorticosteroids until a lo- dose of#lucocorticosteroids until a lo- dose of

inhaled #lucocorticosteroids isinhaled #lucocorticosteroids isreached, then the other controller mayreached, then the other controller may

$e stopped$e stopped..

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treatmenttreatment #ont!-#ont!-

When to stop controllerWhen to stop controller

treatmenttreatment ? ? ?? ? ?

if the patients is asthma remainsif the patients is asthma remains

controlled on the lo-est dose ofcontrolled on the lo-est dose ofcontroller and no recurrence ofcontroller and no recurrence of

symptoms occurs for one year.symptoms occurs for one year.

*INA/ 0112*INA/ 0112

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Aller3en1specific Immunotherapy

9 *reatest benefit has been obtained in the treatment of allergic rhinitis

9 1ochrane review !'((:" ;< R1T of 4+T confirmed efficacy in asthma interms of symptom score, medication and improved hyper responsiveness

9 +mmunotherapy is considered in well assessed and selected cases ofasthma,only after strict environmental avoidance and pharmacologicinterventio including inhaled steroids have failed to control asthma

9 4hould be performed only by a trained physician

9 Asthma constitutes a relative rather than an absolute indication

Douglass et.al.1997, Thorax, 52 (Suppl) 522-529

Abramso ! et.al."o#hrae Database Syst $e% 2&&',

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Com$limentary and Alternati(emedi!ine

Although in many countries traditional methods of healing Although in many countries traditional methods of healing

are used, their efficacy has not yet been established andare used, their efficacy has not yet been established andtheir use can thereforetheir use can therefore

not be recommendednot be recommended

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Severe exacerbation ofasthma

>ncrease in dyspnea, -ith patient una$leto complete one sentence in one $reath+>n childrenI interrupted feedin#,a#itation

9espiratory rate E )0:minute @eart rate E 120:minute Fse of accessory muscles of respiration

4ulsus parado6us E 25 mm @# 4 D *0% personal $est or D

100!:minute +in adults

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+tepwise management o%a#"te severe asthma

Ho"r 1

+i 6y#en administration,

+ii hydration +intra3enousCuids,

+iii Fp to four doses ofinhaled sal$utamol -ithipratropium,

+i3 intra3enoushydrocortisone +100 m# or

oral prednisolone +0*0m#.

Ho"r 2Ho"r 2

+i our more doses of inhaledsal$utamol -ithipratropium,

+ii intra3enous aminophylline,

+iii intra3enous ma#nesiumsulfate 2#m,

+i3 su$cutaneous ter$utaline:adrenaline 0.)0.5 m#+0.01m#:# child K )

doses,

Patent not respondn+ or deteroratn+ n 0 $ours,Patent not respondn+ or deteroratn+ n 0 $ours,

-F- IMMDIAT%-F- IMMDIAT%

h % hWh % h R Prasad Lucknow


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When to re%er the When to re%er the

patient?patient? ia#nosis unclear or in dou$t. Atypical si#ns or symptoms +si#ni7cant

e6pectoration E *0 m!:day, haemoptysis,monophonic -hee/e.

ailure to respond to treatment for o3er 1 month. ther conditions complicatin# asthma or its

dia#nosis necessitatin# additional -orup. =e3ere persistent asthma.

!ife threatenin# asthma +cyanosis, mentalo$tundation. Acute se3ere asthma not respondin# -ithin t-o

hours of intensi3e therapy

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Ast$ma n Adults> prmary !are le#elAst$ma n Adults> prmary !are le#el

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Asthma %ana3ement !ro3ram9Asthma %ana3ement !ro3ram9

SummarySummary

Asthma can be effectively controlled, although it Asthma can be effectively controlled, although it

cannot be curedcannot be cured

/ffective asthma management programs include/ffective asthma management programs includeeducation, ob=ective measures of lung function,education, ob=ective measures of lung function,

environmental control, and pharmacologic therapyenvironmental control, and pharmacologic therapy

A stepwise approach to pharmacologic therapy is A stepwise approach to pharmacologic therapy isrecommended. The aim is to accomplish therecommended. The aim is to accomplish the

goals of therapy with the least possible medicationgoals of therapy with the least possible medication

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Asthma %ana3ement !ro3ram9Asthma %ana3ement !ro3ram9

SummarySummary 6continue&86continue&8

Anything more than mild, occasional asthma is Anything more than mild, occasional asthma is

more effectively controlled by suppressingmore effectively controlled by suppressinginflammation than by only treating acuteinflammation than by only treating acute

bronchospasmbronchospasm

The availability of varying forms of treatment,The availability of varying forms of treatment,cultural preferences, and differing health carecultural preferences, and differing health care

systems need to be consideredsystems need to be considered

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BD 2008

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1hronic 1ough with e%cessive mucus secretion

for most days out of : months in each of two or more successive years without other specific

cause of cough !asthma, bronchiectasis, tub.

etc."

C$ron! Bron!$ts

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Abnormal enlargement of the air

spaces distal to the terminalbronchioles accompanied by

destruction of their walls, andwithout obvious fibrosis.

mp$ysema

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A m"lti#entri# st"!( on epi!emiolog(A m"lti#entri# st"!( on epi!emiolog( R Prasad Lucknow


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A m"lti#entri# st"!( on epi!emiolog( A m"lti#entri# st"!( on epi!emiolog(

o% COPD an! its relationship witho% COPD an! its relationship with

toa##o smo$ing an! environmentaltoa##o smo$ing an! environmental

toa##o smo$e epos"retoa##o smo$e epos"re )525 su$&ects a#ed )5 years or a$o3e -ere studied.)525 su$&ects a#ed )5 years or a$o3e -ere studied. 4 -as dia#nosed in .1% of total su$&ects.4 -as dia#nosed in .1% of total su$&ects.

4re3alence of 4 is 5% amon# men and ).2% in4re3alence of 4 is 5% amon# men and ).2% in

-oman-oman

ale emale ratio is 1.5* I1ale emale ratio is 1.5* I1 Bidi Gs ci#arette =moer is 8.2% and 5.% odds ratioBidi Gs ci#arette =moer is 8.2% and 5.% odds ratio

for 4 -as hi#her for men, s indi3iduals lo-erfor 4 -as hi#her for men, s indi3iduals lo-er

socioeconomic status and ur$an +or mi6ed residencesocioeconomic status and ur$an +or mi6ed residence

en3ironmental to$acco smoe e6posure amon#en3ironmental to$acco smoe e6posure amon#

nonsmoers had an or 1.+5% > 1.211.*1.nonsmoers had an or 1.+5% > 1.211.*1.

om$ined e6posure to $oth ;= and and solid fuelom$ined e6posure to $oth ;= and and solid fuel

com$ustion had hi#her or than for ;= e6posure alone.com$ustion had hi#her or than for ;= e6posure alone.

7 F Jindal etal IJCD 2006;48:23-2G7 F Jindal etal IJCD 2006;48:23-2G

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BD 2008

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How to !iagnose COPD ?How to !iagnose COPD ?

ia#nosis is considered -henia#nosis is considered -hen hronic cou#hIhronic cou#hI 4resent on most days for at4resent on most days for at

least ) months in a year for 2 or more consecuti3eleast ) months in a year for 2 or more consecuti3e years. ou#h may $e either present throu#h out years. ou#h may $e either present throu#h outthe day or only intermittently. ou#h is sometimesthe day or only intermittently. ou#h is sometimesnocturnal in naturenocturnal in nature

hronic sputum productionhronic sputum production

BreathlessnessBreathlessness Acute 6acer$ations Acute 6acer$ations 9is factors9is factors

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ia#nosis of 4ia#nosis of 4

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AST>%A C;!D CLINICAL DIFFERENCESAST>%A #s C;!D9 CLINICAL DIFFERENCES

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SymptomsSymptoms Varia+leVaria+le !ersistent!ersistent

%A C;!DC;!D

;nset;nset ?sually chil&hoo&?sually chil&hoo& ?sually )"@yr?sually )"@yr

CourseCourse Varia+le7 remissions !ro3ressi#eVaria+le7 remissions !ro3ressi#e

rarely pro3ressi#erarely pro3ressi#e

Smo(in3Smo(in3 SometimesSometimes ?sually?sually

Resp to +&Resp to +& oo&oo& !oor !oor

Resp to steroi&sResp to steroi&s oo&oo& !oor !oor

AST>%A #s4 C;!D9 CLINICAL DIFFERENCESAST>%A #s4 C;!D9 CLINICAL DIFFERENCES

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IV9 Very se#ere />?5>1 @ ;(B />? @:( or @ ?5>1 @ ;(B />? @ -( C ?5>1 @ ;(B />? @


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+taging o% COPD ase! on+taging o% COPD ase! on

+pirometr( +pirometr(

At 9is At 9is


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+taging o% COPD ase! ong g

s(mptoms4 signs4 7 min"te wal$s(mptoms4 signs4 7 min"te wal$

test an! pea$ epirator( *ow ratetest an! pea$ epirator( *ow rate

=ymptoms=ymptoms =i#ns=i#ns * min* min-al test-al test 44

At 9is At 9is


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$&ecti3es of 4$&ecti3es of 4

ana#ementana#ement 2revent disease progression

Relieve symptoms

+mprove e%ercise tolerance

+mprove health status

2revent and treat e%acerbations 2revent and treat complications

Reduce mortality

Minimi3e side effects from treatment

C4PD Mana+ement

C4PD M t R Prasad Lucknow


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?. Assess an& monitor &isease

'4 Re&uce ris( factors

$4 %ana3e sta+le C;!D E&ucation

!harmacolo3ic

Non1pharmacolo3ic

"4 %ana3e e5acer+ations

C4PD Mana+ement

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Inter#entions that Inter#ention that

impro#e sur#i#al impro#e symptoms

Smo(in3 Cessation !harmacotherapy

;' for >ypo5emia Reha+ilitation

E&ucation

Trainin3 an& E5ercise

!sycholo3ical Support

Nutrition

Sur3ery

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ssess and onitor iseasessess and onitor isease

>istory 1hronic cough

4putum

dyspnea

>istory of ris( factor

C4PD Mana+ement

4moking5Domestic smoke

/nvironment

/T diseases

!hysical e5amination

/>?5>1 @ ;( post bronchodilator />?@ -(

not fully reversible

%easurement of Air flo* Limitation9 4pirometry !gold standard"

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Reduction of total personal e%posure to tobacco smoke,

occupational dusts and chemicals and indoor and outdoor

air pollutants.

'4Re&uce Ris( Factors

C4PD Mana+ement

4moking cessation is the single most effectiveand costeffective

intervention to reduce the risk of developing 1$2D and stop its progression.



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A4E 4ystematically identify alltobacco users at every visit.

AD>+4/ 4trongly urge all tobaccousers to Fuit.

A44/44 Determine willingness to makea Fuit attempt.

A44+4T Aid the patient in Fuitting. ARRA*/ 4chedule followup contact.

Strate3ies To uit Smo(in3

C4PD Mana+ement



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2.9educe 9is actors +ontd.2.9educe 9is actors +ontd.

4everal effective pharmacotherapies fortobacco dependence are available and at least

one of these medications should be added to

counseling if necessary, and in the absence of

contraindications.

C4PD Mana+ement

Strate3ies To uit Smo(in3

/e!"#tion o% other ris$/e!"#tion o% other ris$ R Prasad Lucknow


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/e!"#tion o% other ris$/e!"#tion o% other ris$

%a#tors%a#tors A3oid open $urnin# of crop residue. A3oid open $urnin# of crop residue. Fse of -ater to suppress dust.Fse of -ater to suppress dust. Wearin# mass at -or place in areas of dust.Wearin# mass at -or place in areas of dust. Fse smoeless LchullahsMFse smoeless LchullahsM =u$stitution of solid fuels -ith !4N or electricity=u$stitution of solid fuels -ith !4N or electricity 9educin# the duration of stay in the itchen or9educin# the duration of stay in the itchen or

place of fuel use and $y co3erin# nose and mouthplace of fuel use and $y co3erin# nose and mouth-ith a thin cloth near the source of com$ustion-ith a thin cloth near the source of com$ustion

6posure to ;= can $e reduced $y stoppin# :6posure to ;= can $e reduced $y stoppin# :minimisin# indoor smoin# and $y adeKuateminimisin# indoor smoin# and $y adeKuate 3entilation. 3entilation.



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).ana#ement of sta$le 4).ana#ement of sta$le 4

/ducation

2harmacological treatment

on 2harmacological treatment

C4PD Mana+ement

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)reatment g"i!elines)reatment g"i!elines! !i i %

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!epen!ing "pon severit( o%!epen!ing "pon severit( o%

COPDCOPDMil! COPDMil! COPD =hort actin#=hort actin#$ronchodilators,$ronchodilators,-hen needed.-hen needed.

Mo!erate COPDMo!erate COPD 9e#ular treatment9e#ular treatment-ith one:more-ith one:more$ronchodilators.$ronchodilators.

4ulmonary4ulmonaryreha$ilitation.reha$ilitation.

+evere COPD+evere COPD As in moderate As in moderate

4, plus inhaled4, plus inhaled

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3-Management o% stale COPD3-Management o% stale COPD8Cont!-98Cont!-9

Non 1 !harmacolo3ical treatmentNon 1 !harmacolo3ical treatment

C4PD Mana+ementC4PD Mana+ement

• Reha+ilitationReha+ilitation

• ;5y3en therapy;5y3en therapy

• Sur3ical treatmentsSur3ical treatments

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%on+ Term 4?y+en T$erapy%on+ Term 4?y+en T$erapy

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To&yo /


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"4%ana3ement of E5acer+ations"4%ana3ement of E5acer+ations R Prasad Lucknow


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33

Da+noss and Assessment of Se#ertyDa+noss and Assessment of Se#erty

SymptomsSymptoms // In!reased .reat$lessnessIn!reased .reat$lessness

/ In!reased !ou+$ sputum/ In!reased !ou+$ sputum

/ C$an+e n !$ara!ter of sputum/ C$an+e n !$ara!ter of sputum

/ Fe#er,malase,nsomna,fat+ue,!onfuson/ Fe#er,malase,nsomna,fat+ue,!onfuson %un+ fun!ton test%un+ fun!ton test

PF ;11%5mn or F3;;"11% nd!ates se#erePF ;11%5mn or F3;;"11% nd!ates se#eree?a!er.atone?a!er.aton

AB*AB*


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40 t$erapy / (Pao0 71 mm H+ or Sao0 91: ) Bron!$odlators

"4%ana3ement of E5acer+ations 6Cont&48


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9sudden de#elopment of restn+ dyspnoea

9 4nset of ne' s+ns (e"+" !yanoss, dro'sness, !onfuson, flaps, edema)

9 Falure of e?a!er.aton to respond to ntal med!al mana+ement

9 S+nf!ant !o mor.dtes su!$ as da.etes or asso!ated !arda! dsease

9 Ne'ly o!!urrn+ arr$yt$mas

9 Da+nost! un!ertanty

Patent referral for $osptalaton

4 ana#ement at primary '4 ana#ement at primary ' R Prasad Lucknow


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# p y# p y

=econdary care=econdary care

I am Stll %earnn+


91/102:"ank 9 :"ank 9

)reatment o% A#"te +evere)reatment o% A#"te +evere R Prasad Lucknow


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Asthma Asthma

β22 agonistagonist

=al$utamol 2.5 O 5 m#=al$utamol 2.5 O 5 m# $y ne$uli/er e3ery$y ne$uli/er e3eryoror 20 min 6 1 hr20 min 6 1 hr

;er$utaline 510 m#;er$utaline 510 m# ;hen e3ery hour;hen e3ery houroror for 12 hoursfor 12 hours

ontinuous ne$uli/ation if no impro3ementontinuous ne$uli/ation if no impro3ement

>.G. =al$ut. +250>.G. =al$ut. +250 µµ# or ;er$ut. 500# or ;er$ut. 500 µµ# in 10 min.# in 10 min.then P12.5%then P12.5% µµ#:min.#:min.

=: or >:=: or >: ββ22 a#onist Oa#onist O ;er$ut. =ulph. =: 0.25 m# +0.01 ml:Q# upto 2 dose;er$ut. =ulph. =: 0.25 m# +0.01 ml:Q# upto 2 dose



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)reatment o% A#"te +evere Asthma Asthma

2 agonist #ont!--2 agonist #ont!-- ormoterol O eKually eecti3e asormoterol O eKually eecti3e as ββ22 a#onista#onist

due to rapid onset of actiondue to rapid onset of action !ess side eects!ess side eects

But costlyBut costly ther optionsther options

!e3a$uterol +$ut costly!e3a$uterol +$ut costly

Whether continuous or intermittent ?Whether continuous or intermittent ?

=tudies say O continuous ;:t O lo-er heart rate ' less=tudies say O continuous ;:t O lo-er heart rate ' less

decrease in Q decrease in Q HH le3elle3el

)reatment o% A#"te +evere)reatment o% A#"te +evereAsthmaAsthma

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Asthma Asthma A!renaline A!renaline

pinephrine +AdrenalineR =: or >:Rpinephrine +AdrenalineR =: or >:R >nhaled =.A>nhaled =.A ββ22 a#on. not a3aila$lea#on. not a3aila$le


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)reatment o% A#"te +evere Asthma Asthma

Anti#holinergi# Anti#holinergi#

>pratropium $romide ne$uli/er>pratropium $romide ne$uli/er

Dose 'Dose '

E1 yrsE1 yrs 0. ml O 2.0 ml +100 O 500 mc#0. ml O 2.0 ml +100 O 500 mc#

*1 yrs*1 yrs 0. ml O 1.0 ml +100 O 250 mc#0. ml O 1.0 ml +100 O 250 mc#

) to times per day) to times per day

D* yrsD* yrs 0. ml O 1.0 ml +100250 mc#0. ml O 1.0 ml +100250 mc#

>pratropium -ith>pratropium -ith ββ22 a#onist produces $ettera#onist produces $etter$ronchodilatation than either dru# alone$ronchodilatation than either dru# alone

)reatment o% A#"te +evere)reatment o% A#"te +evere

A hA th

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Asthma Asthma )heoph(line)heoph(line

Kui3alent $ronchodilator eect to inhaledKui3alent $ronchodilator eect to inhaled ββ22 a#onist $uta#onist $utmore side eects.more side eects.

Alternate therapy Alternate therapy

Appears to add $ene7t in children -ith near fatal asthma Appears to add $ene7t in children -ith near fatal asthma

recei3in# a##ressi3e re#imen of >Grecei3in# a##ressi3e re#imen of >G ββ22 a#onist, inhaleda#onist, inhaled

ipratropium $romide, >G systemic #lucocorticosteroids.ipratropium $romide, >G systemic #lucocorticosteroids.

!oadin# ose I!oadin# ose I

>.G. aminophylineSS 5.* m#:# in 20 ml #lucose in 1020 min.,>.G. aminophylineSS 5.* m#:# in 20 ml #lucose in 1020 min.,

if no ;heophyline in precedin# 8 hrs.if no ;heophyline in precedin# 8 hrs.


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Asthma Asthma

)heoph(line #ont!--)heoph(line #ont!-- aintenance dose I 0.5 O 0. m#:#:hr. i.3. infusionaintenance dose I 0.5 O 0. m#:#:hr. i.3. infusion

ose 3ariation O Acc. ;o dru# clearanceose 3ariation O Acc. ;o dru# clearance

m#:#:hrm#:#:hr m#:daym#:day


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p ( n#rease!n#rease!

metaolismmetaolism i#arette smoin#i#arette smoin# ari&uana smoin#ari&uana smoin#

hildhoodhildhood

@i#h protein diet@i#h protein diet

orticosteroidsorticosteroids 9ifampicin9ifampicin

4henytoin4henytoin

4heno$ar$itone4heno$ar$itone

ar$ama/epinear$ama/epine

< De!reased meta.olsmDe!reased meta.olsm

i(er diseasei(er disease

C@C@

CDCD

ne#moniane#monia

In&ant 6 mont old ageIn&ant 6 mont old age

@y$oemia@y$oemia

Hiral In&e!tionHiral In&e!tion

A!#te Illness in ICA!#te Illness in IC

e(er e(er

rytromy!in Clindamy!inrytromy!in Clindamy!in

,roleandomy!in,roleandomy!in

Ci$ro&loa!inCi$ro&loa!in



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Asthma Asthma

orticosteroidsorticosteroids ral steroids are as eecti3e as >.G.ral steroids are as eecti3e as >.G.

9eKuires hrs to produce clinical imp.9eKuires hrs to produce clinical imp.

oseose

ral predni. 0*0 m#:day +12 m#:#:dayral predni. 0*0 m#:day +12 m#:#:day

>.G. hydrocortisone )0000 m#:day>.G. hydrocortisone )0000 m#:day

ethyl predni. *080 m#:dayethyl predni. *080 m#:day



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Asthma Asthma

orticosteroids contd..orticosteroids contd..>ndications>ndications

oderate to se3ere e6acer$ationoderate to se3ere e6acer$ation


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Asthma Asthma Other )reatmentOther )reatment

Anti$iotics Anti$iotics

>nhaled mucolytic a#ent>nhaled mucolytic a#ent


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Asthma Asthma >nfants and "oun# hildren>nfants and "oun# hildren

9ehydration necessary9ehydration necessary

Documents

Copd & Asthma in Trivendram 22 Oct 2009