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An Overview – Based on
GINA Management Guide Lines
Bronchial Asthma
Dr. R.V.S.N. Sarma, M.D., M.Sc. (Canada),
Consultant Physician & Chest Specialist
visit us at: www.drsarma.in
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When you can't breathe, nothing else matters®
When you can't breathe, nothing else matters®
American Lung Association
American Lung Association
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A Paradigm Shift In
The Management
Bronchial Asthma
Time Now, to Unlearn Our
Age Old Outdated Practices
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• GINA www.ginasthma.org• ACCP www.chestnet.org• ATS www.thoracic.org• BTS www.brit-thoracic.org.uk• NICE www.nice.uk.org• Chest Net www.chestnet.net• CDC www.cdc.nih.gov• NAEPP www.naepp.nhlbi.org• CTS www.respiratoryguidelines.ca
Resources Consulted – Sincere Thanks
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What Is Asthma ?
Primarily – Allergic inflammation of AW
Secondary – Bronchoconstriction
– Airway Hyper-reactivity - AWHR
– Recurrent wheezing, coughing and SOB
– Airflow limitation is variable and often reversible
– Infiltration of dendritic cells, mast cells, eosinophils and lymphocytes
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The Huge Gap
Many patients are not detected Many do not seek medical attention Many have no access to health service Many doctors do not do what is right Stigma associated with the label Broken marriages, alliances Missed diagnosis (Bronchitis, LRI)
Mechanism of Asthma
INFLAMMATIONINFLAMMATION
Risk Factors (for development of asthma)
AWHR Airflow Limitation
Symptoms (SOB, cough, wheeze)
Risk Factors(for exacerbations)
Innate AtopyInnate Atopy
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Pathology of Asthma
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Risk Factors for Asthma
Causal Factors Indoor Allergens
– Domestic mites– Animal Allergens– Cockroach Allergens– Fungi moulds
Outdoor Allergens– Pollens– Fungi, RSV
Occupational exposure
Host Factors Genetic Atopy ( IgE), AWHR
Contributing Factors Respiratory infections Small size at birth, Obesity Diet Air pollution
– Outdoor pollutants– Indoor pollutants
Smoking – Active / Passive
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House Dust Mite
Use bedding encasementsUse bedding encasements
Wash bed linens weeklyWash bed linens weekly
Avoid feather filled onesAvoid feather filled ones
Limit stuffed toys to those Limit stuffed toys to those
that can be washedthat can be washed
Reduce humidity levelReduce humidity level
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Cockroaches
Remove as many water and food sources as possible to avoid cockroaches. Left over food, moisture, drains, open cupboards are the common sources – kitchen and toiletsDon’t eat anywhere except in the dining.
Remove as many water and food sources as possible to avoid cockroaches. Left over food, moisture, drains, open cupboards are the common sources – kitchen and toiletsDon’t eat anywhere except in the dining.
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PETS
People allergic to pets should notPeople allergic to pets should not have them in the house.have them in the house. At a minimum, do not allow pets in At a minimum, do not allow pets in the bedroom.the bedroom.
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Molds – Fungus
Eliminating molds may help control asthma exacerbations.Eliminating molds may help control asthma exacerbations.
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History and patterns of symptoms Physical examination Measurements of lung function
– Peak flow meter– Spirometry
Diagnosis of Asthma
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Patient History
Recurrent attacks or episodes of wheezing?
Troublesome cough, worse particularly at night
Cough after physical activity (e.g. playing)?
H/o seasonal attacks of breathing problems.
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Main Symptom Clues
Do the patient’s colds ‘go to the chest’ or take more than 10 days to resolve?
Does the patient use any medication ? Is there (relief) ? (e.g. bronchodilator) when symptoms occur
If the patient answers “YES” to any of the above questions, suspect asthma.
Remember, the commonest cause of persistent cough is asthma
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Physical Examination
Wheeze
Usually heard without a stethoscope Dyspnea
Rhonchi heard with a stethoscopeUse of accessory muscles
Remember
Absence of symptoms at the time of examination does not exclude the diagnosis of asthma
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Hyper-expansion of the thorax
Increased nasal secretions or nasal
polyps
Atopic dermatitis, eczema, or other
allergic skin conditions
Physical Examination
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Screening Test – Peak Flow
Diagnosis of asthma can be suspected by demonstrating the presence of airway obstruction using Peak flow meter.
Peak Flow Meter is a basic tool in a GPs office
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Diagnostic Test – The PFT
Diagnosis of asthma can be confirmed by demonstrating the
presence of reversible airway obstruction using Spirometry.
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Spirometry Results
FVC Forced Vital Capacity
FEV1 Forced Expiratory Volume
in the first second
FEV1÷FVC Ratio of the above two
PEFR Peak Expiratory Flow Rate
FET Forced Expiratory Time
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Spirometry Normal Values
1. There are no fixed ‘Normal’ values
2. Dependent on age, sex, ht, wt, ethnicity
3. Observed value expressed as predicted value % FVC Normal if > 80% of predicted FEV1 Normal if > 80% of predicted FEV1/FVC At least 75% PEFR Normal if > 80% of predicted FET Less than 4 seconds
Typical FEV1 Tracings
11Time (sec)Time (sec)22 33 44 55
FEV1FEV1
VolumeVolume
Normal Subject
Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)
Each FEV1 curve representsthe best of three repeat efforts
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> 80%
60%
40%
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Obstructive v/s Restrictive
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Goals In Asthma Control
Achieve and maintain control of symptoms
Prevent asthma episodes or attacks
Minimal use of reliever medication
No emergency visits to doctors or hospitals
Maintain normal activity levels, including exercise
Maintain PF as close to normal as possible
Minimal (or no) side effects from medicine
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Tool Kit We Have
Relievers (Quick) Controllers (long term) Peak Flow meter Spirometry Patient education
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Asthma Treatment Today
We can completely control symptoms
Make their life as normal as possible
Treatable by general practice physicians
We do not need to be Chest Specialists!
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It is a Dual Problem
1. Bronchial inflammation – perpetual
1. Allergic inflammation and edema
2. Inflammatory mediators – perpetuate
3. edema and excite bronchospasm
4. Bronchial hyper reactivity to triggers
2. Bronchospasm – acute attacks
Needs two different types of medicines
Relievers & Controllers
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Certain Abbreviations
ICS Inhaled corticosteroids IBD Inhaled bronchodilators SABA Short acting β agonists LABA Long acting β agonists LTA Leukotrine antagonists OCS Oral corticosteroids SR Sustained release Ach B Acetylcholine blockers
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What Are Relievers?
Spasm needs reliever– Bronchodilator drugs– Rescue medications– Quick relief of symptoms– Used during acute attacks– Action lasts for 4-6 hrs– Not for regular use at all
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Relievers
Rapid-acting inhaled β2-agonists– Salbutamol, Levo Salbutamol
Anti-cholinergics– Ipatropium, Tiotropium
Short-acting oral β2-agonists– Salbutamol, Levo Salbutamol, Terbutaline
Systemic glucocorticosteroids (Status Asthmaticus) Theophylline (oral) – (evidence C)
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Prevent future attacks– Reduce allergic inflammation– Reduce inflammatory mediators– Reduce hyper-responsiveness– Long term control of asthma– Prevent airway remodeling– For regular use – well or ill
What Are Controllers ?
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Are we giving the right drug?
Are we giving the drug in right form?
Are we using the correct technique?
Let Us Question
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The Story Of Asthma Treatment
N orm al
R egularInha ledS teroid
P artlyTreated
In flam ed (untreated)
Remodeled
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All Asthma drugs should ideally be
taken through the inhaled route.
Most Important
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What Changes Their Life ?
ICS are the most potent and effective anti-
inflammatory medication currently
available for Asthma *
*GINA (NHLBI & WHO Workshop Report)
*Guidelines for the diagnosis and management of Asthma NIH, NHLBI
ICSInhaled corticosteroids
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Corticosteroids ??
Inhaled medicines ??
Let Us Believe First
Patients’ wrong beliefParents / Grand parentsNeighbors / ‘friends’
First of all, let us believe in scienceLet us explain and convince themLet us change their lives – to happy lives
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Let Us Unlearn
ICS and IBD are the Rx.
Adrenaline s/c, thank heavens we forgot !!
Deriphyllin + Betnesol I.V - give up please - Must !!
Oral SABA and LABA – Restrict their use !!
Theophylline in any form beware !!
Systemic steroids – Not at all the choice !!
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Instead of asthma
controlling our patient,
Remember
allow our patient to
control his / her asthma
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Why Inhalation Treatment
Oral Slow onset of action Large dosage used Greater side effects Erratic absorption Not useful in acute
illness
Inhaled route Rapid onset of action Less amount of drug Drug delivered to the site Better tolerated Treatment of choice
in acute symptoms
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Preventers
Inhaled corticosteroids
Budesonide/ beclomethasone/ fluticasone – use any Start (400-1000 mcg/day approx. in 2 divided doses) Maintain for 3 months Taper slowly and keep at 200 mcg Safe for long-term use (years)
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They are very safe Even in small children for several years 30% of Olympic athletes use ICS Not anabolic (performance-enhancing) steroid Even highest ICS dose is safer than low dose
oral steroid or beta agonist Best “Addiction” for asthmatics
ICS – How safe are they?
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ICS are safe even for a child
400 mcg/day (budesonide) Over 9 years of continuous use No growth retardation Uncontrolled asthma causes growth retardation
Pedersen & Agertoft NEJM 2000
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Not All Are Same !!
Beclomethasone 6 hrly + Salbutamol 6th hrly Budesonide 12 hrly + Salmeterol 12 hrly Salmeterol 12 hrly + Ipatropium 12 hrly Fluticasone 24 hrly + Formoterol 24 hrly Formoterol 24 hrly + Tiotropium 24 hrlyChoice is based on1. If need is urgent and uncontrolled – 6 hrly2. If need is maintenance, well contr. – 12 hrly3. If stabilized and wants convenience – 24 hrly
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Pregnancy and Asthma
Don’t x-ray (if possible) All asthma medication is safe Even oral corticosteroids are safe for exacerbations Uncontrolled asthma during pregnancy is a serious
risk factor for foetal distress and anoxia
Thorax Supplement
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Leukotrine Modifiers
Oral Leukotrine antagonist – anti inflammatory
Not as effective as inhaled steroid
May be first-line for 2 to 5 yr. olds.
Montelukast available; Zafirlukast is not in India
4 mg, 5 mg, 8 mg tabs available
Can be add on to ICS, IBD inhalers
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Step Up and Down – Acute Asthma
SABA (IBD) in full doses SABA Increase frequency or Nebulize SABA as above + IPA (IBD), then add OCS (Methyl prednisolone) 30-60 mg for 3 to 10 days - add ICS (1000 mcg) / day and maintain for 6 weeks minimum Gradually bring down doses and maintain with ICS If symptoms are not relieved – Check the technique compliance Look for aggravating factors like
– GE Reflux, Emotions/ Stress, Sinusitis, Allergic Rhinitis ? Role for Theophylline; Oral SABA or LABA not very useful
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The Step Care Approach - Prevent
ICS ICS + LABA (IBD) ICS + LABA (IBD) + Double Dose ICS ICS (DD) + LABA + LTA (oral) ICS (DD) + LABA + LTA + OCS ICS (DD) + LABA + LTA + OCS + TIO (IBD) SR Theophylline may be an add on SABA or LABA Oral + IPA (IBD) may be a useful add on No long acting steroid injections No injectable or short acting Theophylline
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Controlled
Partly controlled
Uncontrolled
Exacerbation
LEVEL OF CONTROL
Maintain and find lowest controlling step
Consider stepping up to gain control
Step up until controlled
Treat as exacerbation
THERAPEUTIC ACTION
TREATMENT STEPS
REDUCE INCREASE
STEP
1STEP
2STEP
3STEP
4STEP
5
RE
DU
CE
INC
RE
AS
E
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Why doctors don’t use inhalation Rx ?
Status quo – No mood to unlearn “My practice is good or ‘great’ Oral therapy is easy Too busy Difficulty in convincing Cost (in fact, in the long run economical) Headache to explain
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Drug Delivery Options
Metered dose inhalers (MDI)
Dry powder inhalers (Rota haler)
Dry powder compressed for Disc haler
Spacers / Holding chambers
Nebulizers
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Demonstration of the correct technique
Ask the patient to demonstrate to you the technique
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pMDI – Metered Dose Inhalers Rota halers, Disk halers Space halers Zerostats Nebulizers Oxygen mixed delivery Oral tablets, syrups Parenteral – I.M or I.V use
1. Dexterity
2. Hand grip strength
3. Co-ordination
4. Severity of ROAD
5. Educational level
6. Age of the patient
7. Ability to inhale and synchronize
Drug Delivery - Options
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What Drug Delivery Method ?
Very young or very old MDI + LV Spacer Elderly MDI + SV spacer Young children > 7 yrs DPI (Rota haler) Adults - educated MDI alone Adults - no co-ordination DPI (Rota haler) Clinic setting MDI + Spacer Clinic - emergency Nebulizer
Choice is to be individualized; Trial and error may be needed; Cost may be a factor
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SpacerSpace halers
RotahalerDry powder Inhaler
Metered dose inhaler or MDI
Inhalation Devices
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MDI + Large Volume Spacer
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The Zerostat Advantage
1. Non-static spacer made up of polyamide material
2. Increased respirable fraction; Increased deposition of drug in the airways
3. Increased aerosol half-life; Plenty of time for the patient to inhale after actuation of the drug
4. No valve; No dead space; Less wastage of the drug
5. Small, portable, easy to carry, child friendly
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Disk haler – Nebulizer
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Nebulizer Therapy
1. Severe breathlessness despite using inhalers
2. Assessment should be done for improvement
3. Choice between a facemask or mouth piece
4. Equipment servicing and support are essential
5. 0.5 ml of Ipa + 0.5 ml of Sal + 5 ml of Nacl (not DW)
6. If decided to use ICS (FEV1 < 50%) - 0.5 ml of Buduso.
7. 15 minutes and slow or moderate flow rate
8. Can be repeated 2 to 3 times a day – Mouth Wash
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Patient Education
Explain nature of the disease (inflammation) Explain action of prescribed drugs Stress the need for regular, long-term therapy That way only we can convince Allay fears and concerns Peak flow testing Symptom, treatment diary
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Patient Education
Asthma is a common disorder
It can happen to anybody, May not be life long
It is not caused by supernatural forces
Asthma is not contagious, All kin needn’t be affected
Recurrent attacks of cough with or without wheeze
Between attacks people with asthma lead normal lives
In most cases, there is some family history of allergy
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Can be effectively controlled, although can’t be cured.
Effective asthma management programs include education, objective measures of lung function, environmental control, and pharmacologic therapy.
A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication.
Patient Education
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A little time spent talking to our patients –
really is a great investment.
This may make all the difference between
a happy life and pulmonary invalidity
Yours Faithfully Urges
Life Time Happiness
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Can we dare to make
them pulmonary invalids ?
Let Us Give Them
Life Time Happiness