bronchial asthma

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National Institute of Health National Institute of Health 2007 Asthma Guideline 2007 Asthma Guideline Expert Panel Report (EPR) -3 Expert Panel Report (EPR) -3 Bronchial Asthma Bronchial Asthma is a chronic is a chronic inflammatory inflammatory disorder of the disorder of the airways characterized by airways characterized by bronchial hyper-responsiveness bronchial hyper-responsiveness to a variety of stimuli which to a variety of stimuli which lead to episodes of wide spread lead to episodes of wide spread bronchial narrowing which is bronchial narrowing which is largely largely reversible reversible either either spontaneously or with treatment. spontaneously or with treatment.

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Guidelines for asthma management in adults

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Page 1: Bronchial asthma

National Institute of Health National Institute of Health 2007 Asthma Guideline2007 Asthma Guideline

Expert Panel Report (EPR) -3Expert Panel Report (EPR) -3

Bronchial AsthmaBronchial Asthma is a chronic is a chronic inflammatory inflammatory disorder of the airways characterized by disorder of the airways characterized by bronchial hyper-responsivenessbronchial hyper-responsiveness to a variety of to a variety of stimuli which lead to episodes of wide spread stimuli which lead to episodes of wide spread bronchial narrowing which is largely bronchial narrowing which is largely reversiblereversible either spontaneously or with treatment. either spontaneously or with treatment.

Page 2: Bronchial asthma

112233

PathogenesisPathogenesis

1)1) Lumen: Lumen: Mucus plugsMucus plugs

2)2) Mucosa: Mucosa: SwellingSwelling

3)3) Smooth Muscles: Smooth Muscles: SpasmSpasm

Page 3: Bronchial asthma

– Atopy, the genetic predisposition for the development of an immunoglobulin E (IgE)-mediated response to common aeroallergens, is the strongest identifiable predisposing factor for developing asthma.

– However, not all people with allergies have asthma, and not all not all people with allergies have asthma, and not all cases of asthma can be explained by allergic response.cases of asthma can be explained by allergic response.

– Viral respiratory infections are one of the most important causes of asthma exacerbation.

– In some patients, persistent changes in airway structure occur, including sub-basement fibrosis, mucus hypersecretion, injury to epithelial cells, smooth muscle hypertrophy, and angiogenesis (remodeling)

Page 4: Bronchial asthma

Old Old && New Asthma Guidelines: New Asthma Guidelines:What has What has notnot changed changed

Initial therapyInitial therapy is determined by assessment of is determined by assessment of asthma severityasthma severity– Ideally, before the patient is on a long-term controllerIdeally, before the patient is on a long-term controller

Stepping therapyStepping therapy up or down is based on how well up or down is based on how well asthma controlasthma control is achieved.is achieved.

Inhaled corticosteroids (ICS)Inhaled corticosteroids (ICS) are the preferred first-line therapy for are the preferred first-line therapy for asthmaasthma

Systemic steroidsSystemic steroids can still be used to treat asthma exacerbations can still be used to treat asthma exacerbations Peak flows and written asthma action plans are recommended for Peak flows and written asthma action plans are recommended for

asthma self managementasthma self management – Especially in moderate and severe persistent asthma, or for those Especially in moderate and severe persistent asthma, or for those

with a history of severe exacerbations or poorly controlled asthmawith a history of severe exacerbations or poorly controlled asthma

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4 Components of Asthma Management 4 Components of Asthma Management

Component 1Component 1:: Measures of Asthma Measures of Asthma Diagnosis & AssessmentDiagnosis & Assessment• DiagnosisDiagnosis• Differential diagnosisDifferential diagnosis• Assessment of severity Assessment of severity (intrinsic disease intensity)(intrinsic disease intensity)• Assessment of control Assessment of control (response to treatment)(response to treatment)• Assessment of risk Assessment of risk (probability of future morbid events)(probability of future morbid events)

Component 2Component 2:: EducationEducation for a Partnership in asthma care for a Partnership in asthma care

Component 3Component 3:: Control of Control of Environmental Factors & Environmental Factors & Comorbid ConditionsComorbid Conditions

Component 4Component 4:: MedicationsMedications

Page 6: Bronchial asthma

Component 1Component 1

Measures of Asthma Measures of Asthma Diagnosis & AssessmentDiagnosis & Assessment

Page 7: Bronchial asthma

Diagnosis of AsthmaDiagnosis of AsthmaTo establish a diagnosis of To establish a diagnosis of

asthma the clinician should asthma the clinician should determine thatdetermine that::

– Episodic symptoms of Episodic symptoms of airflow obstruction or airflow obstruction or airway hyperresponsiveness airway hyperresponsiveness are presentare present

– Airflow obstruction is at Airflow obstruction is at least partially reversibleleast partially reversible

– Alternative diagnoses are Alternative diagnoses are excluded.excluded.

AsthmaAsthma COPDCOPD

EpisodicEpisodicWorse early Worse early

morningmorningMucoid sputumMucoid sputum

History of other History of other allergiesallergies

PersistentPersistentConstant all Constant all

daydayMucopurulentMucopurulent

sputumsputumHistory of History of smokingsmoking

Page 8: Bronchial asthma

Methods to Establish Diagnosis Methods to Establish Diagnosis

– Medical historyMedical history: Atopy, provoking factors: Atopy, provoking factors– Physical exam:Physical exam: respiratory distress respiratory distress– Spirometry:Spirometry: Obstructive hypoventilation, BD Obstructive hypoventilation, BD

reversibility, bronchial provocation.reversibility, bronchial provocation.– PFM:PFM: (Peak Flow Meter) (Peak Flow Meter)– ABG.ABG.

Page 9: Bronchial asthma

Key Indicators: Diagnosis of AsthmaKey Indicators: Diagnosis of Asthma

Has/does the patient:Has/does the patient:– had an attack or recurrent attacks of wheezing?had an attack or recurrent attacks of wheezing?– have a troublesome cough at night?have a troublesome cough at night?– wheeze or cough after exercise?wheeze or cough after exercise?– experience wheezing, chest tightness, or cough experience wheezing, chest tightness, or cough

after exposure to airborne allergens or after exposure to airborne allergens or pollutants?pollutants?

– symptoms improved by appropriate asthma symptoms improved by appropriate asthma treatment?treatment?

Page 10: Bronchial asthma

Classification of Asthma Severity in Adults Classification of Asthma Severity in Adults >> 12 Years 12 Years

IntermittentPersistent

Mild Moderate Severe

Before starting medications, severity assessed by impairment

Symptoms < 2 d/w > 2 d/w daily continuous

Nighttime Awakening

< 2 x/m > 2 x/m > 1 x/w nightly

Activity Limitation

None Minor Moderate Extreme

SABA Use < 2 d/w > 2 d/w daily daily

FEV1 > 80% P > 80% P 60 – 80% P < 60% P

FEV1/FVC Normal Normal Reduced < 5% Reduced>5%

On medications, severity assessed by lowest level of treatment required to maintain control

Step 1 Step 2 Step 3 or 4 Step 5 or 6

Risk: Expected Exacerbations requiring Systemic Steroids/Year

0 - 1 > 2 > 2 > 2

and consider short course oforal systemic corticosteroids

Step 4 or 5Step 3Step 2Step 1

Recommended Stepfor Initiating Treatment

(See figure 4 5 for treatment steps.)In 2 6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly.

• Normal FEV1between exacerbations

Extremely limitedSome limitationMinor limitationNoneInterference with normal activity

Several timesper day

Daily>2 days/weekbut not daily, and

not more than1x on any day

2 days/weekShort-actingbeta2-agonist use for symptom control (not

prevention of EIB)

2/year (see note)0 1/year (see note)

• FEV1 <60% predicted

• FEV1 >60% but <80% predicted

• FEV1 >80% predicted

• FEV1 >80% predicted

• FEV1/FVCreduced >5%

• FEV1/FVC reduced 5%

• FEV1/FVC normal• FEV1/FVC normal

Risk

Relative annual risk of exacerbations may be related to FEV1.

Classification of Asthma Severity12 years of age

Consider severity and interval since last exacerbation.Frequency and severity may fluctuate over time for patients in any severity category.

Impairment

Normal FEV1/ FVC:8 19 yr 85%

20 39 yr 80%40 59 yr 75%60 80 yr 70%

PersistentComponents of Severity

Exacerbationsrequiring oral

systemic corticosteroids

Lung function

Often 7x/week>1x/week butnot nightly

3 4x/month2x/monthNighttime awakenings

Throughout the dayDaily>2 days/week but not daily

2 days/weekSymptoms

SevereModerateMildIntermittent

FE

V1/

FV

C

Page 11: Bronchial asthma

Classification of Asthma Control in Adults Classification of Asthma Control in Adults >> 12 Years 12 Years

Well Controlled

Not Well Controlled

Poorly Controlled

Symptoms < 2 d/w > 2 d/w continuous

Nighttime Awakening

< 2 x/m 1 – 3 x/w > 4x/w

Activity Limitation

None Moderate Extreme

SABA Use < 2 d/w > 2 d/wSeveral times

daily

FEV1 > 80% P 60 – 80% P < 60% P

PFR > 80% PB 60 – 80% PB < 60% PB

ATAQ 0 1 - 2 > 3

ATAQ: Asthma Therapy Assessment Questionnaire

PB: Personal Best

Page 12: Bronchial asthma

Asthma Therapy Assessment Questionnaire (ATAQ)Asthma Therapy Assessment Questionnaire (ATAQ)

0 :0 : Well Controlled Well Controlled 1 - 2 :1 - 2 : Not Well Controlled Not Well Controlled >> 3 : 3 : Poorly Controlled Poorly Controlled

>5 > 5

Page 13: Bronchial asthma

Component 2Component 2

Education for a Partnership in Education for a Partnership in Asthma CareAsthma Care

Page 14: Bronchial asthma

Key Educational MessagesKey Educational Messages– Significance of diagnosisSignificance of diagnosis– Inflammation as the underlying cause Inflammation as the underlying cause – Controllers vs. quick-relieversControllers vs. quick-relievers– How to use medication delivery devicesHow to use medication delivery devices– Triggers, including 2Triggers, including 2ndnd hand smoke hand smoke– PFM (peak flow monitoring) can be helpful to:PFM (peak flow monitoring) can be helpful to:

1.1. Detect early changes in asthma control that require Detect early changes in asthma control that require adjustments in treatmentEvaluate responses to changes adjustments in treatmentEvaluate responses to changes in treatmentin treatment

2.2. Provide a quantitative measure of impairmentProvide a quantitative measure of impairment

– Need for continuous, on-going interaction w/the clinician to Need for continuous, on-going interaction w/the clinician to step up/down therapystep up/down therapy

– Annual influenza vaccine Annual influenza vaccine

Page 15: Bronchial asthma

How to Use Metered Dose Inhalers

The health-care provider should evaluate inhaler technique at each visit.

Page 16: Bronchial asthma

MDI with Spacer (Holding Chamber) Spacers can help patients who

have difficulty with inhaler use.

The mouth piece may be equipped with a mask or a valve

Properly used MDI with VHC is as effective as nebulizer therapy.

Page 17: Bronchial asthma

Nebulizer

Machine produces a mist of the medication

Used for small children or for severe asthma episodes

No evidence that it is more effective than an inhaler used with a spacer

Page 18: Bronchial asthma

Peak Flow ChartPeak Flow Chart

People with People with moderate or moderate or severe asthma severe asthma should take should take readings:readings:– Every morningEvery morning– Every eveningEvery evening– After an After an

exacerbationexacerbation– Before inhaling Before inhaling

certain certain medicationsmedications

Page 19: Bronchial asthma

Self management education is Self management education is essential and should be integrated essential and should be integrated into all aspects of care; requires into all aspects of care; requires repetition and reinforcementrepetition and reinforcement

Provide Provide allall patients with a patients with a writtenwritten asthma action plan (esp if astma is asthma action plan (esp if astma is severe or poorly controlled) that severe or poorly controlled) that includes 2 aspects:includes 2 aspects:– Daily managementDaily management– How to recognize & How to recognize &

handle worsening asthma handle worsening asthma symptomssymptoms

Regular review of the status of Regular review of the status of patients asthma controlpatients asthma control

Develop an active partnership with Develop an active partnership with the patient and family.the patient and family.

Tailor the plan to needs of each Tailor the plan to needs of each patient.patient.

Asthma Action Plan

Page 20: Bronchial asthma

Component 3Component 3

Control of Environmental Factors Control of Environmental Factors && Comorbid Conditions that Affect AsthmaComorbid Conditions that Affect Asthma

Page 21: Bronchial asthma

Environmental FactorsEnvironmental Factors Patients should:Patients should:– Reduce exposure to allergens & irritants. Reduce exposure to allergens & irritants. – Avoid exertion outdoors when levels of air Avoid exertion outdoors when levels of air

pollution are high.pollution are high.– Avoid use of nonselective beta-blockers.Avoid use of nonselective beta-blockers.Clinicians shouldClinicians should::– Look for other chronic co-morbid conditions, Look for other chronic co-morbid conditions,

particularly when asthma control is not achieved.particularly when asthma control is not achieved.– Look for occupational exposures, particularly in Look for occupational exposures, particularly in

those with new onset work related asthma.those with new onset work related asthma.– Encourage patients to receive a yearly influenza Encourage patients to receive a yearly influenza

vaccine (inactivated).vaccine (inactivated).– Consider allergen immunotherapy when Consider allergen immunotherapy when

appropriate.appropriate.

Page 22: Bronchial asthma

Component 4Component 4

MedicationsMedications

Page 23: Bronchial asthma

22 general classes:general classes: Long-term control medications:Long-term control medications:

– Corticosteroids (mainly ICS, occasionally OCS).Corticosteroids (mainly ICS, occasionally OCS).– Long Acting Beta Agonists (LABA’s)Long Acting Beta Agonists (LABA’s)– Leukotriene Modifiers (LTM)Leukotriene Modifiers (LTM)– Cromolyn & NedocromilCromolyn & Nedocromil– Methylxanthines:Methylxanthines: ( (Sustained-release theophylline) Sustained-release theophylline)

Quick- relief medications:Quick- relief medications:– Short acting Beta Agonists (SABA’s)Short acting Beta Agonists (SABA’s)– Systemic corticosteroidsSystemic corticosteroids– AnticholinergicsAnticholinergics

Page 24: Bronchial asthma

Safety of Inhaled CorticosteroidsSafety of Inhaled Corticosteroids– ICS’s are the most effective long-term therapy available, ICS’s are the most effective long-term therapy available, – well tolerated & safe at recommended doseswell tolerated & safe at recommended doses– The potential but small risk of adverse events from the use The potential but small risk of adverse events from the use

of ICS treatment is well balanced by their efficacyof ICS treatment is well balanced by their efficacy– Local SE: hoarseness, oral candidiasis.Local SE: hoarseness, oral candidiasis.– Systemic SE: delayed linear growth in children, other Systemic SE: delayed linear growth in children, other

steroid effects.steroid effects.

Patients should rinse their mouths (rinse and spit) after Patients should rinse their mouths (rinse and spit) after (ICS) inhalation(ICS) inhalation

Use the lowest dose of ICS that maintains asthma control: Use the lowest dose of ICS that maintains asthma control: – Evaluate patient adherence and inhaler technique as well as Evaluate patient adherence and inhaler technique as well as

environmental factors before increasing the dose of ICSenvironmental factors before increasing the dose of ICS Monitor linear growth in childrenMonitor linear growth in children

Page 25: Bronchial asthma

Safety of Long-Acting BetaSafety of Long-Acting Beta22-Agonists -Agonists (LABA’s)(LABA’s)– Adding a LABA to the treatment of patients whose asthma is not well Adding a LABA to the treatment of patients whose asthma is not well

controlled on low- or medium-dose ICS improves lung function, controlled on low- or medium-dose ICS improves lung function, decreases symptoms, and reduces exacerbations and use of SABA for decreases symptoms, and reduces exacerbations and use of SABA for quick relief. quick relief.

– However, FDA analysis of studies showed an However, FDA analysis of studies showed an increased risk of severe increased risk of severe exacerbationsexacerbations of asthma symptoms and of asthma symptoms and death death associated with LABA use. associated with LABA use.

– For patients who have asthma not sufficiently controlled with ICS alone, For patients who have asthma not sufficiently controlled with ICS alone, the option to increase the ICS dose should be given the option to increase the ICS dose should be given equal weightequal weight to the to the option of the addition of a LABA to ICSoption of the addition of a LABA to ICS

– It is not currently recommended that LABA be used for treatment of It is not currently recommended that LABA be used for treatment of acute symptoms or exacerbationsacute symptoms or exacerbations

– LABAs are not to be used as monotherapy for long-term control. LABAs are not to be used as monotherapy for long-term control. Combined preparations ensure compliance for this, eg Symbicort Combined preparations ensure compliance for this, eg Symbicort (Formoterol + Budesonide).(Formoterol + Budesonide).

Page 26: Bronchial asthma

– SABAs are the most effective medication for relieving SABAs are the most effective medication for relieving acute bronchospasm.acute bronchospasm.

– Only selective Only selective 2 2 agonists are recommended.agonists are recommended.– SABA administered by the inhaled route provide as SABA administered by the inhaled route provide as

great or greater bronchodilatation with fewer SE than great or greater bronchodilatation with fewer SE than either the parenteral or oral routes.either the parenteral or oral routes.

– Increasing use of SABA treatment or using SABA >2 days Increasing use of SABA treatment or using SABA >2 days a week for symptom relief (not prevention of EIB) a week for symptom relief (not prevention of EIB) indicates inadequate control of asthma.indicates inadequate control of asthma.

– Regularly scheduled, daily, chronic use of SABA is Regularly scheduled, daily, chronic use of SABA is notnot recommended.recommended.

Safety of Short-Acting BetaSafety of Short-Acting Beta22-Agonists -Agonists (SABA’s)(SABA’s)

Page 27: Bronchial asthma

Managing Asthma Long Term Managing Asthma Long Term ““The Stepwise Approach”The Stepwise Approach”

““The goal of asthma therapy is to maintain The goal of asthma therapy is to maintain long-term control of asthma with the least long-term control of asthma with the least amount of medications and hence minimal amount of medications and hence minimal

risk for adverse effects”risk for adverse effects”..

Page 28: Bronchial asthma

Principles of Step Therapy to Maintain ControlPrinciples of Step Therapy to Maintain Control

Step up medication dose if symptoms are not Step up medication dose if symptoms are not controlledcontrolled

If very poorly controlled, consider an increase by 2 If very poorly controlled, consider an increase by 2 steps, add oral corticosteroids, or bothsteps, add oral corticosteroids, or both

Before increasing medication therapy, evaluate:Before increasing medication therapy, evaluate:– Exposure to environmental triggers Exposure to environmental triggers – Adherence to therapyAdherence to therapy– Technique of device use.Technique of device use.– Co-morbiditiesCo-morbidities

Page 29: Bronchial asthma

Follow-up AppointmentsFollow-up Appointments

Visits every 2-6 weeks until asthma control is achievedVisits every 2-6 weeks until asthma control is achieved When control is achieved, follow-up every 3-6 monthsWhen control is achieved, follow-up every 3-6 months Step-down in therapyStep-down in therapy::

– When asthma is well-controlled for at least 3 monthsWhen asthma is well-controlled for at least 3 months Patients may relapse with total discontinuation or Patients may relapse with total discontinuation or

reduction of inhaled corticosteroidsreduction of inhaled corticosteroids

Page 30: Bronchial asthma

IntermittentAsthma

Persistent Asthma: Daily MedicationConsult asthma specialist if step 4 care or higher is required.

Consider consultation at step 3

Step 1

Preferred:SABA PRN

Step 2

Preferred:Low dose ICS

Alternative: Cromolyn, LTRA, Nedocromil or Theophylline

Step 3Preferred:

Low-dose ICS + LABA OR – Medium dose ICS

Alternative: Low-dose ICS + either LTRA, Theophylline, or Zileuton

Step 4

Preferred:Medium Dose ICS + LABA

Alternative:Medium-dose ICS + either LTRA, Theophylline, or Zileuton

Step 5

PreferredHigh Dose ICS + LABA

AND

Consider Omalizumab for patients who have allergies

Step 6

PreferredHigh dose ICS + LABA + oral corticosteroid

AND

Consider Omalizumab for patients who have allergies

Each Step: Patient Education and Environmental Control and management of comorbiditiesSteps 2 – 4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma

Stepwise Approach for Managing Asthma in Youths >12 Years of Age & Adults

•Quick-relief medication for ALL patients -SABA as needed for symptoms: up to 3 tx @ 20 minute intervals prn. Short course of o systemic corticosteroids may be needed.• Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control & the need to step up treatment.

Step down if

possible

(and asthma is well

controlled at least 3

months)

Assess control

Step up if needed

(first check adherence, environmental control & comorbid conditions)

Page 31: Bronchial asthma

Managing Exacerbations of AsthmaManaging Exacerbations of Asthma

Page 32: Bronchial asthma

ExacerbationsExacerbations are acute or subacute episodes of are acute or subacute episodes of progressively worsening shortness of breath, progressively worsening shortness of breath, cough, and wheezing.cough, and wheezing.

Are characterized by decreases in expiratory Are characterized by decreases in expiratory airflow that can be documented and quantified by airflow that can be documented and quantified by spirometry or peak expiratory flow.spirometry or peak expiratory flow.

Page 33: Bronchial asthma

Indications of a Severe AttackIndications of a Severe Attack

Breathless at restBreathless at rest Leaning forwardLeaning forward Speaks in words rather than complete Speaks in words rather than complete

sentences sentences AgitatedAgitated Peak flow rate less than 60% of normalPeak flow rate less than 60% of normal

Page 34: Bronchial asthma

Early treatment of asthma exacerbations is the best strategy for managementEarly treatment of asthma exacerbations is the best strategy for management::

Patient education includes a written asthma action plan (AAP) to guide patient Patient education includes a written asthma action plan (AAP) to guide patient self management of exacerbations‑self management of exacerbations‑– especially for patients who have moderate or severe persistent asthma especially for patients who have moderate or severe persistent asthma

and any patient who has a history of severe exacerbationsand any patient who has a history of severe exacerbations A peak flow based plan for patients who have difficulty perceiving airflow ‑ ‑A peak flow based plan for patients who have difficulty perceiving airflow ‑ ‑

obstruction and worsening asthma is recommendedobstruction and worsening asthma is recommended

– Recognition of early signs of worsening asthma & taking Recognition of early signs of worsening asthma & taking prompt actionprompt action

– Appropriate intensification of therapy, often including a Appropriate intensification of therapy, often including a short course of oral corticosteroidsshort course of oral corticosteroids

– Removal or avoidance of the environmental factors Removal or avoidance of the environmental factors contributing to the exacerbationcontributing to the exacerbation

– Prompt communication between patient and clinician.Prompt communication between patient and clinician.

Page 35: Bronchial asthma

Classifying Severity of Asthma ExacerbationsClassifying Severity of Asthma Exacerbations

SeveritySeverity Dyspnoea FEV1 %POr PEF/PB

Clinical Course

MildExertional 2 / tachypnoea

> 70

Usually cared for at home Prompt relief with inhaled SABA

Moderate Exertional 340 – 70

Usually requires office or Emergency Department visit

Relief from freq. inhaled SABA Oral systemic corticosteroids

Severe Exertional 4 (at rest)25 - 40

Usually requires ED visit and likely hospitalization

Partial relief from frequent inhaled SABA

PO systemic corticosteroids; some symptoms last >3 days after treatment is begun

Adjunctive therapies are helpful

Life Threatening Too dyspneic to speak

< 25

Requires ED/hospitalization; possible ICU

Minimal or no relief w/ frequent inhaled SABA

Intravenous corticosteroids Adjunctive therapies are helpful

Page 36: Bronchial asthma

What the EPR -3 Does What the EPR -3 Does NOTNOT Recommend Recommend

– Drinking large volumes of liquids or breathing warm, Drinking large volumes of liquids or breathing warm, moist air moist air (e.g., the mist from a hot shower)(e.g., the mist from a hot shower)

– Using over-the-counter products such as antihistamines Using over-the-counter products such as antihistamines or cold remediesor cold remedies

– Although pursed-lip and other forms of controlled Although pursed-lip and other forms of controlled breathing may help to maintain calm during respiratory breathing may help to maintain calm during respiratory distress, these methods do distress, these methods do not not bring about bring about improvement in lung functionimprovement in lung function