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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Age Old Outdated Practices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