asthma by dr sarma
TRANSCRIPT
Dr.Sarma@works 1
LIFE TIME HAPPINESS
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When you can't breathe, nothing else
matters®American Lung
Association
3 Dr.Sarma@works
CD format of today’s presentation is ready
1. Asthma, COPD and Basics of Spirometry
In addition it, also contains
2. ECG workshop presented earlier
3. Guidelines on Hypertension treatment
This can be used in Computer & DVD player
Important Announcement
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1. ACCP www.chestnet.org2. ATS www.thoracic.org3. BTS www.brit-thoracic.org.uk4. COPD profess.
www.copdprofessional.com5. GOLD www.goldcopd.com6. NICE www.nice.uk.org7. Chest Net www.chestnet.net8. CDC www.cdc.nih.gov9. NAEPP www.naepp.nhlbi.org10.COPD Rapid series by ELSEVIER
COPD and Asthma Resources
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CHRONIC LUNG DISEASES
Pulmonary Tuberculosis Restrictive lung diseases Suppurative lung disease Obstructive lung diseases
– Bronchial Asthma– Chronic bronchitis– Emphysema and
Their differentiations
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AN OVERVIEW - GINAMANAGEMENT GUIDE LINES
Dr. Sarma.R.V.S.N., M.D., M.Sc (Canada)
Consultant Physician and chest specialist
# 5, Jayanagar, Tiruvallur 602 001+ 91 9894- 60593, (4116) 260593
ASTHMA
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WHAT IS ASTHMA ?
Primarily it is an allergic inflam-matory disorder of the airways
Infiltration of mast cells, eosinophils and lymphocytes
Secondary broncho-constriction Airway hyper-responsiveness Recurrent episodes of wheezing,
coughing and shortness of breath Airflow limitation is variable and
often reversible and wide spread
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BURDEN OF ILLNESS
15- 20 million asthmatics in India. A recent study conducted in Delhi
established asthma prevalence to be 12% in school children.
Significant cause of school/work absence. Health care expenditures very high. Morbidity and mortality are on the rise.
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THE HUGE GAP
Patients are not detected Do not seek medical attention No access to health service Stigma associated with the label Broken marriages, alliances Missed diagnosis (bronchitis, LRTI)
MECHANISM OF ASTHMA
INFLAMMATIONINFLAMMATION
Risk Factors (for development of asthma)
AirwayHyper responsiveness Airflow
Limitation
Symptoms- (shortness of breath, cough, wheeze)Risk Factors
(for exacerbations)
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ASTHMA : PATHOLOGY
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RISK FACTORS FOR ASTHMA
Predisposing Factors Atopy (↑ IgE)
Causal Factors Indoor Allergens
– Domestic mites– Animal Allergens– Cockroach Allergens– Fungi moulds
Outdoor Allergens– Pollens– Fungi, RSV
Occupational Sensitizers
Contributing Factors Respiratory infections Small size at birth Diet Air pollution
– Outdoor pollutants– Indoor pollutants
Smoking– Passive Smoking– Active Smoking
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HOUSE DUST MITE
Use bedding encasementsUse bedding encasements Wash bed linens weeklyWash bed linens weekly Avoid down fillingsAvoid down fillings Limit stuffed toys to thoseLimit stuffed toys to those that can be washedthat can be washed Reduce humidity levelReduce humidity level
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COCKROACHES
Remove as many Remove as many water and food water and food sources as sources as possible to avoid possible to avoid cockroaches.cockroaches.
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PETS
People allergic to pets should not People 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 mold may help control asthma exacerbations.Eliminating mold 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
Has the patient had an attack or recurrent episodes of wheezing?
Does the patient have a troublesome cough, worse particularly at night, or on awakening?
Does the patient cough after physical activity (eg. Playing)?
Does the patient have breathing problems during a particular season (or change of season)?
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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 ? (e.g. bronchodilator) when symptoms occur ? - Is there a (relief) response?
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 EXAM
Wheeze -Usually heard without a stethoscope
Dyspnoea -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 EXAM
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SCREENING TEST
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
PEFR amplitude ?
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DIAGNOSTIC TEST
Diagnosis of asthma can be confirmed by demonstrating the presence of reversible airway obstruction using Spirometry.
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SPIROMETRY
Let me now take you through to the understanding of the basics of spirometry
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SPIROMETRY
Basic Issues
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LUNG FUNCTION TESTS
Tests of VentilationTests of DiffusionTests of PerfusionTests for V-P
Mismatch
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LUNG FUNCTION TESTS
Tests of VentilationTests of DiffusionTests of PerfusionTests for V-P
Mismatch
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VENTILATION
Peak Expiratory Flow Rate– Simple, Peak flow meter is used
Flow volume loop , Flow time curve– Detailed, Spirometry is used
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PEAK FLOW METER
Diagnosis of ASTHMA or COPD can beconfirmed by demonstrating the presenceof airway obstruction using Spirometry.
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PEFR - Pros and Cons
Advantages– With in 1 to 2 minutes,– Inexpensive (meter costs less than Rs.1000)– Simple, useful for frequent follow up use
Disadvantages– Very much effort dependent– Insensitive to small changes– Small airways cannot be assessed– Large inter & intra subject variation;↓accurate
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SPIROMETRY
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Spirometry - Pros and Cons
Advantages– Evaluates smaller as well as larger airways– Relatively easy to use and maintain– Reversibility can be tested with IBD and steroids– Diagnostic as well as management assessments
Disadvantages– Cost about 50,000 + computer and printer– Takes time to perform – 10 to 15 minutes– Requires training – at least one day course
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Spirometry Maneuver
In single breath testA few normal tidal respirationsThen deeeeep inspirationMomentary breath holdingVery forced and fast expiration
– As hard and as fast as he/she can blow outThen deep, quick and full inspirationRepeat at least 3 times – take the best
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Spirometry Results
FVC Forced Vital CapacityFEV1 Forced Expiratory
Volume in the first second FEV1÷FVC Ratio of the above twoPEFR Peak Expiratory Flow
RateFET Forced Expiratory Time
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Spirometry Normal Values
1. There are no fixed ‘Normal’ values2. Dependent on age, sex, ht, wt, ethnicity3. 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
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Obstructive v/s Restrictive
Parameter Normal Obstructive Restrictive
Problem ‘Air out’ and ‘Air in’ normal
Unable to get‘Air out’
Unable to get‘Air in’
FVC 80 % of pred Normal or ↓ ↓,↓TLC
FEV1 80 % of pred ↓-80% or less Normal
FEV1 ÷ FVC Min. of 75% ↓-70% or less Normal or ↑
PEFR 80 % of pred ↓-80% or less Normal
FET in sec Less than 4 Prolonged > 4 Normal - < 4
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Flow-Volume, Volume-Time Graphs
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Normal Flow-Volume Loop
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Flow-Volume Loop in disease
Mild reversible obstruc Severe irreversible obstr Severe restrictive dis
ASTHMA COPD ILD
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Office Spirometry
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BACK TO ASTMA
Now, with this understanding of spirometry, let us proceed to look at the management of Asthma
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CLASSIFICATION OF SEVERITY
STEP 4Severe
PersistentSTEP 3
Moderate Persistent
STEP 2Mild
Persistent
STEP 1Intermittent
The presence of one of the features of severity is sufficient to place a patient in that category.
Global Initiative for Asthma (GINA) WHO/NHLBI, 2002
Symptoms NighttimeSymptoms FEV1
CLASSIFY SEVERITYClinical Features Before Treatment
ContinuousLimited physical activity
DailyUse 2-agonist dailyAttacks affect activity>1 time a week but <1 time a day< 1 time a weekAsymptomatic and normal PEF between attacks
Frequent
>1 time week
>2 times a month
<2 times a month
<60% predictedVariability >30%
>60%-<80% predictedVariability >30%
>80% predictedVariability 20-30%
>80% predictedVariability <20%
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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 pulmonary function as close to normal
as possible Minimal (or no) side effects from medicine
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TOOL KIT WE HAVE
Relievers (Quick) Preventers (long term) Peak Flow meter Spirometry Patient education
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ASTHMA Rx. in INDIA TOADAY
Completely control symptoms and Make their life normal As good as abroad (even better) General practice physicians Doesn’t need Chest Physicians !
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IT IS A DUAL PROBLEM
1. Bronchial inflammation – perpetual1. Allergic inflammation and edema2. Inflammatory mediators – perpetuate3. edema and excite bronchospasm4. Bronchial hyper reactivity to triggers
2. Bronchospasm – acute attacks This needs two different types of
medicines – relievers & preventers
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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
Short acting 2 agonists - SABASalbutamol, TerbutalineLevo-salbutamol (Levolin)
Anti-cholinergicsIpatropium
Xanthines Theophylline (Deriphyllin group)
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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 PREVENTERS ?
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PREVENTERS
Xanthines Theophylline SRMast cell stabilizersSodium cromoglycateNedocromil sodiumKetotifen, CeterizineCombinationsSalmeterol/FluticasoneFormoterol/BudesonideSalbutamol/Beclomethasone
CorticosteroidsPrednisolone, Betamethasone
Beclomethasone, Budesonide
Fluticasone
Long acting 2 agonists-LABABambuterol, Salmeterol
Formoterol, Bambuderol
Anti-leukotrienesMontelukast, Zafirlukast, Pranlukast
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CERTAIN ABBREVIATIONS
ICS Inhaled corticosteroids IBD Inhaled bronchodilators SABAShort acting βagonists LABA Long acting βagonists LTA Leukotrine antagonists OCS Oral corticosteroids SR Sustained release AchB Acetyl choline blockers
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NEW APPROACHES
Omalizumab injection Monoclonal antibody against Immunoglobin E (anti-IgE) Monoclonal antibody to block
the allergic antibody, IgE
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PLEASE REMEMBER
If our patient uses reliever medication every day, or even more than three or four times a week, preventer medication must be added to the treatment plan and reliever medication has to be with drawn.
GINA Workshop Report, December 2000
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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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WHAT HAPPENS WITH WRONG Rx. ?
N orm al
Inflam ed(Asthm a)
Partly Treated
F ixed O bstruction(Lead P ipe)
R em odelledA irw ay
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THE STORY OF ASTHMA TREATMENT
N orm al
R egularInha ledS teroid
PartlyTreated
Inflam 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), December 1995*Guidelines for the diagnosis and management of Asthma NIH,
NHLBI, May 1997
ICS
Inhaled corticosteroids
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Corticosteroids ??
Inhaled medicines ??
LET US BELIEVE FIRST
Patients’ wrong beliefParents / Grand parents
Neighbours / ‘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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Instead of asthma controlling our patient
REMEMBER
allow our patient to
control his / her asthma
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WHY INHALATION Rx.
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 of mischief 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 ?
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ICS 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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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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ICS not Effective ?
Check Inhaler Technique /Check Regular Use
Add LABAFormoterol / Salmeterol
Increase dose of inhaled steroid
Add Leukotriene modifier
Add SR Theophylline
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Step up and down - ACUTE SABA (IBD) in full doses SABA Increase frequency or Nebulize SABA as above + IPA (IBD), then add OCS (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 and the compliance with Rx. Look for aggravating factors like
– GE Reflux, Emotions/ stress, Sinusitis– Allergic Rhinitis, Persistent allergens
No 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 add on SABA or LABA Oral + IPA (IBD) may be useful add on No long acting steroid injections No injectable or short acting Theophylline
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Leukotriene Modifiers
Oral leukotrine antagonist – anti inflammatoryNot as effective as inhaled steroidMay be first-line for 2 to 5 yr. olds.Montelukast available; Zafirlukast is not in India4 mg, 5 mg, 8 mg tabs availableCan be add on to ICS, IBD inhalers
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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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Formoterol + Budesonide combination - the Flexible Preventer
Ast
hma
sign
s
Time
2x2 2x2 1x11x21x2
Quicklygains control
Maintainscontrol
Asthmaworsening
Maintainscontrol
Reduce tolowest adequatedose that maintainscontrol
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Why doctors don’t use inhalation therapy
Status quo :“my practice is good or ‘great’”
Oral therapy is easyToo busyDifficulty in convincingCostHeadache to explain
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DRUG DELIVERY OPTIONS
Metered dose inhalers (MDI) Dry powder inhalers (Rotahaler) 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 Rotahalers, Diskhalers Spacehalers 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 COPD
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 (Rotahaler) Adults edu. understood MDI alone Adults no co-ordination DPI (Rotahalers) Clinic setting MDI + Spacer Clinic - emergency Nebulizer
Choice is to be individualizedTrial and error may be neededCost may be a factor
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DRUG DELIVERY - OPTIONS
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SpacerSpacehaler
RotahalerDry powder Inhaler
Metered dose inhaler or MDI
INHALATION DEVICES
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MDI + LARGE VOLUME SPACER
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ROTAHALER – DRY POWDER
Overcomes hand-lung coordination problems encountered with MDIs.
Can be easily used by children, elderly and arthritic patients.
Can take multiple inhalations if the entire drug has not been inhaled in one inhalation.
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THE ZEROSTAT ADVANTAGE
1. Non - static spacer made up of polyamide material2. Increased respirable fraction ® Increased deposition of
drug in the airways3. Increased aerosol half - life ® Plenty of time for the
patient to inhale after actuation of the drug4. No valve ® No dead space ® Less wastage of the drug5. Small, portable, easy to carry ® Child friendly
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DISKHALER – NEBULISER
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NEBULISED THERAPY
1. Severe breathlessness despite using inhalers 2. Assessment should be done for improvement3. Choice between a facemask or mouth piece4. Equipment servicing and support are essential5. Dosage 0.5 ml of Ipatropium +
0.5 ml of Salbutamol + 5 ml of NaCl (not DW)6. If decided to use ICS (FEV1 < 50%) –
0.5 ml of Budusonide is added to the above6. 15 minutes and slow or moderate flow rate7. 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 as anyone else In most cases, there is some family history of allergy
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Asthma can be effectively controlled, although it cannot 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 talkingto our patients - reallyis a great investment.
This may make all the differencebetween a happy life and pulmonary invalidity
YOURS FAITHFULLY REQUESTS
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Can We dare to make them pulmonary invalids ?LET US GIVE THEM
LIFE TIME HAPPINESS