Transcript Asthma by Dr Sarma

LIFE TIME HAPPINESS
Dr.Sarma@works
1
When you can't breathe,
nothing else matters®
American Lung
Association
Dr.Sarma@works
2
Important Announcement
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
Dr.Sarma@works
3
COPD and Asthma Resources
1. ACCP
www.chestnet.org
2. ATS
www.thoracic.org
3. BTS
www.brit-thoracic.org.uk
4. COPD profess. www.copdprofessional.com
5. GOLD
www.goldcopd.com
6. NICE
www.nice.uk.org
7. Chest Net
www.chestnet.net
8. CDC
www.cdc.nih.gov
9. NAEPP
www.naepp.nhlbi.org
10.COPD
Rapid
series
by
ELSEVIER
Dr.Sarma@works
4
CHRONIC LUNG DISEASES




Pulmonary Tuberculosis
Restrictive lung diseases
Suppurative lung disease
Obstructive lung diseases
– Bronchial Asthma
– Chronic bronchitis
– Emphysema and
Their differentiations
Dr.Sarma@works
5
ASTHMA
AN OVERVIEW - GINA
MANAGEMENT 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
Dr.Sarma@works
6
WHAT IS ASTHMA ?






Dr.Sarma@works
Primarily it is an allergic inflammatory 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
7
BURDEN OF ILLNESS





Dr.Sarma@works
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.
8
THE HUGE GAP






Dr.Sarma@works
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)
9
MECHANISM OF ASTHMA
Risk Factors (for development of asthma)
INFLAMMATION
Airway
Hyper responsiveness
Airflow
Limitation
Symptoms- (shortness of
Risk Factors
breath, cough, wheeze)
(for exacerbations)
ASTHMA : PATHOLOGY
Dr.Sarma@works
11
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

Contributing Factors




Respiratory infections
Small size at birth
Diet
Air pollution
– Outdoor pollutants
– Indoor pollutants

Smoking
– Passive Smoking
– Active Smoking
Occupational
Sensitizers
Dr.Sarma@works
12
HOUSE DUST MITE
 Use bedding encasements
 Wash bed linens weekly
 Avoid down fillings
 Limit stuffed toys to those
that can be washed
 Reduce humidity level
Dr.Sarma@works
13
COCKROACHES
Remove as many
water and food
sources as
possible to avoid
cockroaches.
Dr.Sarma@works
14
PETS
 People allergic to pets should not
have them in the house.
 At a minimum, do not allow pets in
the bedroom.
Dr.Sarma@works
15
MOLDS - FUNGUS
Eliminating mold may help control asthma exacerbations.
Dr.Sarma@works
16
DIAGNOSIS OF ASTHMA
History and patterns of symptoms
 Physical examination
 Measurements of lung function

– Peak flow meter
– Spirometry
Dr.Sarma@works
17
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)?
Dr.Sarma@works
18
MAIN SYMPTOM CLUES




Dr.Sarma@works
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
19
PHYSICAL EXAM



Wheeze Usually heard without a stethoscope
Dyspnoea Rhonchi heard with a stethoscope
Use of accessory muscles
Remember Absence of symptoms at the time of
examination does not exclude the
diagnosis of asthma
Dr.Sarma@works
20
PHYSICAL EXAM



Dr.Sarma@works
Hyper-expansion of the thorax
Increased nasal secretions or
nasal polyps
Atopic dermatitis, eczema, or
other allergic skin conditions
21
SCREENING TEST
Diagnosis of asthma can be suspected by
demonstrating the presence of airway
obstruction using Peak flow meter.
PEFR amplitude ?
Peak Flow Meter is a basic
tool in a GPs office
Dr.Sarma@works
22
DIAGNOSTIC TEST
Diagnosis of asthma can be
confirmed by demonstrating
the presence of reversible
airway obstruction using
Spirometry.
Dr.Sarma@works
23
SPIROMETRY
Let me now take you through to
the understanding of the basics
of spirometry
Dr.Sarma@works
24
SPIROMETRY
Basic Issues
Dr.Sarma@works
25
LUNG FUNCTION TESTS
 Tests
of Ventilation
 Tests of Diffusion
 Tests of Perfusion
 Tests for V-P
Mismatch
Dr.Sarma@works
26
LUNG FUNCTION TESTS
 Tests
of Ventilation
 Tests of Diffusion
 Tests of Perfusion
 Tests for V-P
Mismatch
Dr.Sarma@works
27
VENTILATION

Peak Expiratory Flow Rate
– Simple, Peak flow meter is used

Flow volume loop , Flow time
curve
– Detailed, Spirometry is used
Dr.Sarma@works
28
PEAK FLOW METER
Diagnosis of ASTHMA or COPD can be
confirmed by demonstrating the presence
of airway obstruction using Spirometry.
Dr.Sarma@works
29
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
Dr.Sarma@works
30
SPIROMETRY
Dr.Sarma@works
31
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
Dr.Sarma@works
32
Spirometry Maneuver
In single breath test
 A few normal tidal respirations
 Then deeeeep inspiration
 Momentary breath holding
 Very forced and fast expiration
– As hard and as fast as he/she can blow out
Then deep, quick and full inspiration
 Repeat at least 3 times – take the best

Dr.Sarma@works
33
Spirometry Results
FVC
 FEV1
Forced Vital Capacity
Forced Expiratory Volume
in the first second
 FEV1÷FVC Ratio of the above two
 PEFR
Peak Expiratory Flow Rate
 FET
Forced Expiratory Time

Dr.Sarma@works
34
Spirometry Normal Values
1.
2.
3.





There are no fixed ‘Normal’ values
Dependent on age, sex, ht, wt, ethnicity
Observed value expressed as predicted value %
FVC
FEV1
FEV1/FVC
PEFR
FET
Dr.Sarma@works
Normal if > 80% of predicted
Normal if > 80% of predicted
At least 75%
Normal if > 80% of predicted
Less than 4 seconds
35
Obstructive v/s Restrictive
Parameter
Normal
Obstructive
Restrictive
Problem
‘Air out’ and
‘Air in’ normal
FVC
80 % of pred
Unable to get
‘Air out’
Normal or ↓
Unable to get
‘Air in’
↓,↓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
Dr.Sarma@works
36
Flow-Volume, Volume-Time Graphs
Dr.Sarma@works
37
Normal Flow-Volume Loop
Dr.Sarma@works
38
Flow-Volume Loop in disease
ASTHMA
Mild reversible obstruc
Dr.Sarma@works
COPD
ILD
Severe irreversible obstr Severe restrictive dis39
Office Spirometry
Dr.Sarma@works
40
BACK TO ASTMA
Now, with this understanding of
spirometry, let us proceed to look
at the management of Asthma
Dr.Sarma@works
41
CLASSIFICATION OF SEVERITY
CLASSIFY SEVERITY
STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent
STEP 1
Intermittent
Clinical Features Before Treatment
Nighttime
FEV1
Symptoms
Symptoms
Continuous
<60% predicted
Frequent
Limited physical
Variability >30%
activity
Daily
Use b2-agonist
daily
Attacks affect
activity
>1 time a week
but <1 time a day
< 1 time a week
Asymptomatic
and normal PEF
between attacks
>1 time week
>2 times a month
<2 times a month
>60%-<80%
predicted
Variability >30%
>80% predicted
Variability 2030%
>80% predicted
Variability <20%
The presence of one of the features of severity is sufficient to place
Dr.Sarma@works
a patient in that category.
Global Initiative for Asthma (GINA) WHO/NHLBI, 2002
42
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
Dr.Sarma@works
43
TOOL KIT WE HAVE





Dr.Sarma@works
Relievers (Quick)
Preventers (long term)
Peak Flow meter
Spirometry
Patient education
44
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 !
Dr.Sarma@works
45
IT IS A DUAL PROBLEM
1.
Bronchial inflammation – perpetual
1.
2.
3.
4.
Allergic inflammation and edema
Inflammatory mediators – perpetuate
edema and excite bronchospasm
Bronchial hyper reactivity to triggers
2.
Bronchospasm – acute attacks

This needs two different types of
medicines – relievers & preventers
Dr.Sarma@works
46
WHAT ARE RELIEVERS ?







Dr.Sarma@works
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
47
RELIEVERS



Dr.Sarma@works
Short acting b2 agonists - SABA
Salbutamol, Terbutaline
Levo-salbutamol (Levolin)
Anti-cholinergics
Ipatropium
Xanthines
Theophylline (Deriphyllin group)
48
WHAT ARE PREVENTERS ?







Dr.Sarma@works
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
49
PREVENTERS
Corticosteroids
Prednisolone, Betamethasone
Beclomethasone, Budesonide
Fluticasone
Long acting b2 agonists-LABA
Bambuterol, Salmeterol
Formoterol, Bambuderol
Anti-leukotrienes
Montelukast, Zafirlukast, Pranlukast
Dr.Sarma@works
Xanthines
Theophylline SR
Mast cell stabilizers
Sodium cromoglycate
Nedocromil sodium
Ketotifen, Ceterizine
Combinations
Salmeterol/Fluticasone
Formoterol/Budesonide
Salbutamol/Beclomethasone
50
CERTAIN ABBREVIATIONS








Dr.Sarma@works
ICS
IBD
SABA
LABA
LTA
OCS
SR
AchB
Inhaled corticosteroids
Inhaled bronchodilators
Short acting βagonists
Long acting βagonists
Leukotrine antagonists
Oral corticosteroids
Sustained release
Acetyl choline blockers
51
NEW APPROACHES




Dr.Sarma@works
Omalizumab injection
Monoclonal antibody against
Immunoglobin E (anti-IgE)
Monoclonal antibody to block
the allergic antibody, IgE
52
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
Dr.Sarma@works
53
LET US QUESTION
 Are we giving the right drug ?
 Are we giving the drug in right form ?
 Are we using the correct technique ?
Dr.Sarma@works
54
WHAT HAPPENS WITH WRONG Rx. ?
Normal
Inflamed
(Asthma)
Partly Treated
Remodelled
Airway
Dr.Sarma@works
Fixed Obstruction
(Lead Pipe)
55
THE STORY OF ASTHMA TREATMENT
Normal
Inflamed (untreated)
Regular
Inhaled
Steroid
Remodeled
Partly
Treated
Dr.Sarma@works
56
MOST IMPORTANT
All Asthma drugs should ideally be
taken through the inhaled route.
Dr.Sarma@works
57
WHAT CHANGES THEIR LIFE ?
ICS
Inhaled corticosteroids
ICS are the most potent and effective
anti-inflammatory medication currently
available for Asthma *
Dr.Sarma@works
*GINA (NHLBI & WHO Workshop Report), December 1995
*Guidelines for the diagnosis and management of Asthma NIH,
NHLBI, May 1997
58
LET US BELIEVE FIRST
Corticosteroids ??
Inhaled medicines ??
Patients’ wrong belief
Parents / Grand parents
Neighbours / ‘friends’
First of all, let us believe in science
Let us explain and convince them
Let
us
change
their
lives
–
to
happy
lives
Dr.Sarma@works
59
REMEMBER
Instead of asthma controlling
our patient
allow our patient to
control his / her asthma
Dr.Sarma@works
60
WHY INHALATION Rx.
Oral





Inhaled route
Slow onset of action
Large dosage used
Greater side effects
Erratic absorption
Not useful in acute
illness
Dr.Sarma@works

Rapid onset of action

Less amount of drug

Drug delivered to
the site of mischief

Better tolerated

Treatment of choice
in acute symptoms
61
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)
Dr.Sarma@works
62
ICS – HOW SAFE ?
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
Dr.Sarma@works
63
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
Dr.Sarma@works
64
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
Dr.Sarma@works
65
ICS not Effective ?
Check Inhaler
Technique /
Check Regular
Use
Increase dose
of inhaled
steroid
Dr.Sarma@works
Add LABA
Formoterol /
Salmeterol
Add SR
Theophylline
Add Leukotriene
modifier
66
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
Dr.Sarma@works
 No role for Theophylline; Oral SABA or LABA not very useful

67
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
Dr.Sarma@works
68

Leukotriene 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

Dr.Sarma@works
69
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 hrly
Choice is based on
1. If need is urgent and uncontrolled – 6 hrly
2. If need is maintenance, well contr. – 12 hrly
3. If stabilized and wants convenience – 24 hrly

Dr.Sarma@works
70
Formoterol + Budesonide
combination - the Flexible Preventer
Asthma
worsening
Asthma signs
Quickly
gains control
2x2
Dr.Sarma@works
Maintains
control
Maintains
control
1x2
2x2
Time
1x2
Reduce to
lowest
adequate
dose that
maintains
control
1x1
71
Why doctors don’t use
inhalation therapy
Dr.Sarma@works

Status quo :
“my practice is good or ‘great’”

Oral therapy is easy

Too busy

Difficulty in convincing

Cost

Headache to explain
72
DRUG DELIVERY OPTIONS

Metered dose inhalers (MDI)

Dry powder inhalers (Rotahaler)

Spacers / Holding chambers

Nebulizers
Dr.Sarma@works
73
Demonstration of
the correct technique
Ask the patient to demonstrate to
you the technique
Dr.Sarma@works
74
DRUG DELIVERY - OPTIONS
1. Dexterity

pMDI – Metered Dose Inhalers
2. Hand grip strength

Rotahalers, Diskhalers
3. Co-ordination

Spacehalers
4. Severity of COPD

Nebulizers
5. Educational level

Oxygen mixed delivery
6. Age of the patient

Oral tablets, syrups
7. Ability to inhale and
synchronize

Parenteral – I.M or I.V use
Dr.Sarma@works
75
WHAT DRUG DELIVERY METHOD ?







Very young or very old
Elderly
Young children > 7 yrs
Adults edu. understood
Adults no co-ordination
Clinic setting
Clinic - emergency
Dr.Sarma@works
MDI + LV Spacer
MDI + SV spacer
DPI (Rotahaler)
MDI alone
DPI (Rotahalers)
MDI + Spacer
Nebulizer
Choice is to be individualized
Trial and error may be needed
Cost may be a factor
76
DRUG DELIVERY - OPTIONS
Dr.Sarma@works
77
INHALATION DEVICES
Rotahaler
Dry powder Inhaler
Dr.Sarma@works
Metered dose
inhaler or MDI
Spacer
Spacehaler
78
MDI + LARGE VOLUME SPACER
Dr.Sarma@works
79
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.
Dr.Sarma@works
80
THE ZEROSTAT ADVANTAGE
1.
2.
3.
4.
5.
Non - static spacer made up of polyamide material
Increased respirable fraction ® Increased deposition of
drug in the airways
Increased aerosol half - life ® Plenty of time for the
patient to inhale after actuation of the drug
No valve ® No dead space ® Less wastage of the drug
Small, portable, easy to carry ® Child friendly
Dr.Sarma@works
81
DISKHALER – NEBULISER
Dr.Sarma@works
82
NEBULISED THERAPY
1.
2.
3.
4.
5.
6.
6.
7.
Dr.Sarma@works
Severe breathlessness despite using inhalers
Assessment should be done for improvement
Choice between a facemask or mouth piece
Equipment servicing and support are essential
Dosage 0.5 ml of Ipatropium +
0.5 ml of Salbutamol + 5 ml of NaCl (not DW)
If decided to use ICS (FEV1 < 50%) –
0.5 ml of Budusonide is added to the above
15 minutes and slow or moderate flow rate
Can be repeated 2 to 3 times a day – Mouth Wash
83
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
Dr.Sarma@works
84
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
Dr.Sarma@works
85
PATIENT EDUCATION

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.
Dr.Sarma@works
86
YOURS FAITHFULLY REQUESTS

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
Dr.Sarma@works
87
Can We dare to make
LET US GIVE THEM
them pulmonary invalids ?
LIFE TIME HAPPINESS
Dr.Sarma@works
88