Transcript chronic illness

CHRONIC ILLNESS
Asthma, COAD, Epilepsy
and Parkinson’s disease
Asthma
Definition
Characterised by wide variations over short
periods of time in resistance to airflow in
intrapulmonary airways.
Cough or wheeze associated with heightened
airway responsiveness to inhaled histamine.
Inflammatory disorder of the airways, which
are hyperactive in the asthmatic patient.
Pathology
Infiltration of the mucosa with
inflammatory cells
Oedema of the mucosa
Damaged mucosal epithelium
Hypetrophy of mucus glands with
increased mucus secretion
Smooth muscle constriction
Facts
 Underdiagnosed and undertreated
 Unacceptable mortality rate of about 5 per 100000
 About 1 child in 4 or 5 has asthma between the age of 2
and 7
 Most children present as a cough and are free from it by
puberty
 1 adult in 10 has asthma
 3 valuable home “gadgets” to help the asthmatic are the
mini peak flow meter, the large volume spacing device
and the pump with nebuliser
Facts - continue
Focus of management should be on prevention
Measurement of function is vital as “objective
measurement is superior to subjective
measurement”
Doubling the radius of the airway increases the
flow rate 16 times
Causes
 Infections, especially colds
 Allergies to animal fur, feathers, grass pollens, mould
 Allergy to house dust, especially the dust mites
 Cigarette smoke, other smoke and fumes
 Sudden changes in weather or temperature
 Occupational irritants (wood dust, sprays and chemicals)
 Drugs (aspirin, NSAIDs, beta-blockers)
 Certain foods and food additives
 Exercise, especially in a cold atmosphere
 Emotional upsets or stress
Additional points
Patients with asthma should not smoke
Atopic patients should avoid exposure to furred
or feathered domestic animals
About 90% of children with atopic symptoms
and asthma demonstrate positive skin prick
responses to dust mite extract
Clinical features
Wheezing
Coughing
Tightness in the chest
Breathlessness
suspected in children with recurrent
nocturnal cough and in people with
intermittent dyspnoea or chest tightness,
especially after exercise
Investigations
Peak expiratory flow rate
Spirometry: value of <75% for FEV1/VC
ratio indicates obstruction
Measurement of PEFR or spirometry
before and after bronchodilator: >20%
improvement
Inhalation challenge tests
Suboptimal asthma control
 Poor compliance
 Inefficient use of inhaler devices
 Failure to prescribe preventive medications
 Using bronchodilators alone and repeating these drugs
without proper evaluation
 Patient fears
inhaled or oral corticosteroids
aerosols and ozone layer
overdose
developing tolerance
embarrassment
peer group condemnation
Suboptimal asthma control Continue
Doctor’s reluctance to
use corticosteroids
recommend obtaining a mini peak flow meter
recommend obtaining a compressed air-driven
nebuliser unit
Home “Gadgets”
 Measurement of peak expiratory flow (PEF)
PEF meter objective readings
establishment of a baseline of the “patient’s best”
anyone older than 6
warning signs when using PEF
falling of PEFR and poor control
readings less than 70% of normal best
more morning dipping
erratic readings
less response to bronchodilator
 Large volume spacers
increased airway deposition of inhalant and less
oropharyngeal deposition
Management principle
 Aims of management
abolish symptoms and restore normal airway function
maintain best possible lung function at all times
reduce morbidity
control asthma wit h the use of regular anti-inflammatory
medication and relieving doses of beta2 agonist when necessary
 Long-term goals
achieve use of the least drugs, least doses, least side effects
reduce risk of fatal attacks
reduce risk of developing irreversible abnormal lung function
Management principle Continue
 Definition of control of asthma
no
no
no
no
no
no
cough, wheeze or breathlessness most of the time
nocturnal waking due to asthma
limitation of normal activity
overuse of beta2 agonist
severe attacks
side effects of medication
Management plan
Assess the severity of the asthma
Achieve best lung function
Avoid trigger factors
Stay at your best
Know your action plan
Check your asthma regularly
Assessment of severity
 Mild
History : episodic, mild occasional symptoms with exercise
Medication : occasional use of bronchodilator
Best PEFR : normal 100%, PEFR variability : 10-20%
 Moderate
History : symptoms most days, virtually symptomatic on
effective treatment, several known triggers apart from exercise
Medication : needed most days
Best PEFR : 70-100%, PEFR variability : 20-30%
Assessment of severity Continue
 Severe
History : Symptoms most days, wakes at night with
cough/wheeze, chest tightness on waking, hospital admission or
emergency department attendance in past 12 months, previous
life-threatening episodes
Medication : needed more than 3 times a day or high dose
inhaled steroids>800-1200 mcg daily or oral steroids in past 12
months
Best PEFR : 70%, PEFR variability : 30%
Patient education
 Read all about it
 Get to know how severe your asthma is
 Try to identify trigger factors
 Become expert at using your medication and inhalers
 Use your inhalers correctly and use a spacer if necessary
 Know and recognise the danger signs and act promptly
 Have regular checks with doctor
 Have physiotherapy
 Keep fit and take regular exercise
 Keep to ideal weight
Patient education - Continue
 Work out a clear management plan and an action plan
for when trouble strikes
 Get urgent help when danger signs appear
 Learn the value of a peak expiratory flow meter
 Get a peak flow meter to help assess severity and work
out your best lung function
 Keep at your best with suitable medications
 Always carry your bronchodilator inhaler and check that
it is not empty
Pharmacological
treatment
 Anti-inflammatory agents
Inhaled : beclomethasone and budesonide 400g - 2000g BD,
aim to keep below 1600 g, available as metered dose inhaler,
turbuhaler and rotacaps. Side effects are oropharyngeal
candidiasis, dysphonia and bronchial irritation
Rinse mouth out with water and spit out after using inhaled
steroids
Oral : Prednisolone, 1mg/kg/day for 1-2 weeks, can be ceased
abruptly. Long-term use caused osteoporosis, glucose
intolerance, adrenal suppression, thinning of skin and easy
bruising
Sodium cromoglycate : available as dry capsules for inhalation,
metered dose aerosols or nebuliser solution. Side effects are
uncommon
Pharmacological treatment Continue
 Bronchodilators
beta2-agonists : available as metered dose inhaler, a dry powder
and nebuliser solution, produce measurable bronchodilatation in
1-2 minutes and peak effects by 10-20 minutes. Traditional
agents such as salbutamol and terbutaline are short-acting
preparations. The new longer-acting agents include salmeterol
and formoterol
Theophyline derivatives : complementary value but tend to be
limited by side effects and efficacy
Treatment plan
 Very mild asthma : inhaled beta2-agonist prn
 All other grades of severity
regular use of inhaled steroid or SCG
plus inhaled beta2-agonist
plus prophylactic use prior to exercise or allergen challenge of
inhaled beta2-agonist and/or SCG
 If control inadequate
add oral theophyline derivative or inhaled ipratropium
for exacerbations oral prednisolone intermittent use
Inhalation technique
 Open-mouth technique
remove the cap. Shake the puffer vigorously for 1-2 seconds.
Hold it upright to use
hold the mouthpiece of the puffer 4-5 cm away from mouth
tilt your head back slightly with chin up. Open mouth and keep
it open
slowly blow out to a comfortable level
just as you start to breathe in, press the puffer firmly once,
breathe in as far as you can over 3-5 seconds
close your mouth and hold your breath for about 10 seconds,
then breathe out gently
breathe normally for about 1 minute, then repeat
 Closed-mouth technique : close your lips around the
mouthpiece
Inhalation technique - Continue
Usual dose 1 or 2 puffs every 3-4 hours for an
attack
Contact your doctor if you do not get adequate
relief from your usual dose
It is quite safe to increase the dose, such as 4-6
puffs
If you are using your inhaler very often, it
usually means your other asthma medication is
not being used properly
Common mistakes
 Holding the puffer upside down
 Holding the puffer too far away
 Pressing the puffer too early and not inhaling the spray
deeply
 Pressing the puffer too late and not getting enough
spray
 Doing it all too quickly
 Squeezing the puffer more than once
 Not breathing in deeply
Dangerous asthma
High-risk patients
previous severe asthma attack
previous hospital admission
hospital attendance in the past 12 months
long-term oral steroid treatment
carelessness with taking medication
night-time attacks
recent emotional problems
Dangerous asthma - Continue
 Early warning signs
symptoms persisting or getting worse despite adequate
medication
increased coughing and chest tightness
poor response to two inhalations
benefit from inhalations not lasting two hours
increasing medication requirements
sleep being disturbed by coughing, wheezing or breathlessness
chest tightness on waking in the morning
low peak expiratory flow readings
Dangerous asthma - Continue
 Dangerous signs
marked breathlessness, especially at rest
sleep being greatly disturbed by asthma
asthma getting worse quickly, despite medication
feeling frightened
difficulty in speaking, unable to say more than a few words
exhaustion
drowsiness or confusion
silent chest, cyanosis, chest retraction
RR > 25 for adult or > 50 for children
pulse rate > 120 and peak flow < 100 L/min
Dangerous asthma - Continue
Treatment
continuous nebulised salbutamol
parenteral beta2-agonist
corticosteroids
monitor PEF
Asthma in children
Bronchodilators, inhaled or oral, are ineffective
under 12 months
delivery method is a problem in children
in the very young, a spacer with a face mask
can deliver the aerosol medication
PEF rate should be measured in all asthmatic
children older than 6 years
Prophylaxis in children
Sodium cromoglycate by inhalation is the
prophylactic drug of choice in childhood chronic
asthma of mild to moderate severity
A symptomatic response occurs in about 1-2
weeks
No clinical response to SCG, use inhaled
corticosteroids, but risks versus benefits must
always be considered, e.g. growth suppression
and adrenal suppression
When to refer
Doubtful about the diagnosis
For problematic children
For advice on management when asthmatic
control has failed or is difficult to achieve
Practice tips
 Reassure the patient that 6-10 inhaled doses of a beta2-agonist is
safe and appropriate for a severe attack of asthma
 Important to achieve a balance between undertreatment and
overtreatment
 Beware of patients, especially children, manipulating their peak flow
 Get patients to rinse out their mouth with water and spit it out after
inhaling corticosteroids
 Patients who are sensitive to aspirin/salicylates need to be
reminded that salicylates are present in common cold cure
preparations
 Possible side effects of inhaled drugs can be reduced by always
using a spacer with the inhaler, using the medication qid rather
than bd, rinsing the mouth, gargling and spitting out after use, and
using corticosteroid sparing medications
COAD
 Chronic bronchitis
productive cough on most days for at least 3 months of the year
for at least 2 consecutive years in the absence of any other
respiratory disease that could be responsible for such excessive
sputum production
 Emphysema
permanent dilatation and destruction of lung tissue distal to the
terminal bronchioles
 Chronic airflow limitation
physiological process measured as impairment of forced
expiratory flow and is the major cause of dyspnoea in these
patients
Causes
Cigarette smoking
Air pollution
Airway infection
Familial factors
Alpha1 antitrypsin deficiency
Clinical features
Symptoms
onset in 5th or 6th decade
excessive cough
sputum
dyspnoea
wheeze
susceptibility to colds
Clinical features - Continue
 Signs
tachypnoea
reduced chest expansion
hyperinflated lungs
hyper-resonant percussion
diminished breath sounds
pink puffer
blue bloater
signs of respiratory failure
signs of cor pulmonale
Investigations
CXR can be normal
Pulmonary function tests
PEFR
FEV1/FVC reduced
Gas transfer coefficient of CO is low if significant
emphysema
Blood gases
may be normal
Pa CO2 increased, PaO2 decreased
ECG cor pulmonale
Hb and PCV raised
Management
 Advice to patient
stop smoking
avoid places with polluted air and other irritants
go for walks in clean, fresh air
warm dry climate is preferable
get adequate rest
avoid contact with people with colds and flu
 Physiotherapy
chest physiotherapy, breathing exercises and aerobic physical
exercise program
Management - Continue
Drug therapy
bronchodilators
antibiotics : prompt use of antibiotics for acute
episodes of infection (sputum turn yellow or green)
sputum for C/ST and micro
annual influenza vaccine
home oxygen therapy
Community Care
 Support patients in the adaptation of recommended
therapeutic measure to their individual housing and social
situation
 Support patient and their family in the maintenance and
trouble-shooting of technique device
 Involve and train caregiver in supportive measure to promote
stabilisation at home and strengthen social contact
 Reinforce patient adherence to therapeutic regime and
intervention
 Intervene patient during episodes of acute exacerbations of
COAD and refer them to other service providers by
appropriate and tightly triaging
 Maintain and further develop patients’ skill and functional
improvement gained during the rehabilitation process
Patient Selection
 Newly diagnosed and recently hospitalised patient with
impairment/disability not suitable for outpatient
rehabilitation programmes after discharge
 Patient discharged with new respiratory equipment
 Patient with recurrent exacerbations and hospitalisations
despite having having received rehabilitation
 Forgetful patients with poor adherence to treatment
 End-stage patients who want to stay at home
Epilepsy
Tendency to recurrence of seizure
A person should not be labelled as epileptic until
at least 2 attacks have occurred
Both sex equally affected
Runs in some family
An underlying organic lesion becomes more
common in epilepsy presented for the first time
in patient over 25 and thus more detailed
investigations is required
Types of epilepsy
 Generalised seizure affects both cerebral hemispheres
simultaneously from the outset and may be primary or
secondary
tonic clonic seizure : with musicle jerking
tonic seizure : stiffness only
clonic seizure : jerks only
atonic seizure : loss of tone, and drops
absence seizure
myoclonic seizure : bilateral discrete muscle jerks and may LOC
Types of epilepsy - Continue
Partial seizures epileptic discharge begins in a
localised focus of the brain and then spreads out
from this focus
simple partial seizures : consciousness is retained
complex partial seizures : consciousness is clouded
both can evolve into a bilateral tonic clonic seizure
Investigations
 Standard minimum investigations : Ca, fasting glucose,
EEG and syphilis serology
 Chest and skull X-ray
 Brain scan
 Video EEG
 MRI
 CT
Approaches
 Accurate diagnosis of seizure type
 Investigate and treat underlying brain disease
 Decision has to be made about whether drug therapy is
appropriate
 Choice of drug depends on the seizure type, age, sex
and on efficacy in relation to toxicity
 Treatment should be initiated with one drug and pushed
until it controls the events or causes side effects
 If a maximum tolerated dosage of this single drug fails
to control, replace it with an alternative agent
Approaches - Continue
 Add the second drug and obtain a therapeutic effect
before removing the first drug
 Review the need for AED every 12 months. Consider
drug withdrawal if free of seizures for several years
 Special attention to the adverse psychological and social
effects. Emotional and social support is important.
Epilepsy support groups
Drug therapy
 Select the most effective recommended drug for a
specific seizure type
 Young women prefer carbamazepine
 Each drug has specific adverse effects
 Twice daily dosage is usually practical
 Phenytoin should be increased in small increments
 Phenytoin or carbamazepine will bring about control in
at least 80% of patients with tonic clonic seizures
Selection of AED
Type of seizure
First-line therapy
Second-line therapy
Tonic/clonic
Phenytoin or
Phenobarbitone
Absence
Sodium valproate
In young women use
carbamazepine
Sodium valproate
Myoclonic
Sodium valproate
Simple partial
Carbamazepine
Complex partial
Carbamazepine
Ethosuximide or
Clonazepam
Clonazepam
Phenytoin or Sodium
valproate
Sodium valproate or
Clonazepam or
Phenytoin
Adverse drug reactions
 Nausea, dizziness, ataxia, visual disturbance or
excessive tiredness/fatigue indicate excessive dosage of
carbamazepine or phenytoin
 Skin rash
 Gingival hyperplasia
 Hirsutism
 Sodium valproate has rare but potentially serious liver
toxicity and dysmorphogenic effects on foetus
 LFTs should be performed every 2 months for 6 months
after starting sodium valproate
Patient education
 Most patients can achieve complete control of seizures
 Most people lead a normal life
 Good dental care if taking phenytoin
 A seizure in itself will not cause death or brain damage
unless in a risk situation such as swimming
 Patients cannot swallow their tongue during a seizure
 Take special care with open fires
 Encourage patients to cease intake of alcohol
 Adequate sleep
Patient education - Continue
 Driving
applicants for learner’s licence need to be seizure-free for two
years, with an annual medical review for five years following
receipt of the licence
 Employment
if liable to seizures they should not work close to heavy
machinery, in dangerous surroundings, at heights or near deep
water. Careers are not available in some services, such as
police, military, aviation or public transport
 Sport and leisure activities
avoid dangerous sports such as scuba diving, hang-gliding,
parachuting, rock climbing, car racing and swimming alone
Patient education - Continue
 Avoid trigger factors
fatigue
lack of sleep
physical exhaustion
stress
excess alcohol
prolonged flashing lights
 Pregnancy
successful for more than 90%
slightly increased risk of prematurity, low birth weight, mortality,
defects and intervention
fall in AED level
phenytoin (cleft lip and palate and CHD), carbamazepine (spina
bifida), all AED expressed in breast milk
Pitfalls in management
 Misdiagnosis
not all seizures are generalised tonic clonic in type
most common misdiagnosed is complex partial seizures or the
variation of generalised tonic clonic seizures
the diagnosis is based on history rather than EEG
misdiagnosing behavioural disorders (pseudoseizures)
 Overtreatment
polypharmacy
prolonged treatment
drug interactions, especially OCP
When to refer
 uncertainty of diagnosis
 at onset of seizure disorder to help obtain a precise
diagnosis
 when the patient is unwell, irrespective of laboratory
investigation
 when a woman is considering pregnancy or has become
pregnant to obtain therapeutic guidance
 assessment of the prospects for withdrawing treatment
 seizures are not controlled by apparent suitable therapy
Practice tips
 EEG has considerable limitations in diagnosis < 50%
 look for neurofibromatosis
 interactions between AED and OCP, erythromycin and
carbamazepine
 aim to achieve monotherapy
 toxic reaction can occur with phenytoin and
carbamazepine
 should not drive while medication is being adjusted
Parkinson’s disease
Parkinson’s disease is the most common and
disabling chronic neurological disorder
1% of adult >65 year of age
mean age of onset is between 58 and 62
incidence rises sharply over 70 years of age
classic triad : tremor, rigidity, bradykinesia
always consider drug-induced Parkinsonism
(phenothiazines, butyrophenones and reserpine)
Physical signs
Power, reflexes and sensation usually normal
loss of dexterity of rapid alternating movements
and absence of arm swing
increased tone with distraction
frontal lobe signs such as grasp and glabellar
taps
no laboratory test for Parkinson’s
hypothyroidism and depression also cause
slowness of movement
Principles of management
appropriate explanation and education
explain that Parkinson’s disease is slowly
progressive, is improved but not cured by
treatment
support systems
walking sticks to prevent falls and constant care
is required
Pharmacological management
commenced as soon as symptoms interfere with
working capacity or the patient’s enjoyment of
life
levodopa in combination with a decarboxylase
inhibitor in a 4:1 ratio
Bromocriptine can be used especially with the
levodopa “on-off” phenomenon
selegiline promises to be an effective first-line
drug
Treatment strategy
 Mild (minimal disability)
levodopa (low dose) or selegiline
 Moderate (independent but disabled)
levodopa
add if necessary - bromocriptine or selegiline
 Severe (disabled, dependant on others)
levodopa maximum tolerated dose + bromocriptine or selegiline
consider antidepressants
Long-term problems
 After 3-5 years of levodopa treatment side effects may
appear in about 1/2 of patients
involuntary movements (use lower dose + bromocriptine)
end of dose failure (reduce duration of effect to 2-3 hours only)
“on-off” phenomenon (sudden inability to move with recovery in
30-90 minutes)
 Contraindicated drugs
phenothiazines
butyrophenones
MAOI
Main side effects
 Nausea and vomiting
 involuntary dyskinetic movements
 psychiatric disturbances
 on-off phenomena
 end of dose failure
 dry mouth
 nausea
 dizziness, fatigue
 severe psychiatric disturbances are more common with
bromocriptine
Practice tips
 levodopa is the gold standard
 longer-acting levodopa may reduce the “end of dose”
failure
 ensure that a distinction is made between drug-induced
involuntary movements and tremor of Parkinson’s
disease
 keep the dose of levodopa as low as possible to avoid
drug-induced involuntary movements
 in elderly fractured hip always consider Parkinson’s
disease
 balance of psychosis and Parkinson’s disease
 don’t fail to attend to the need of the family
The End
Thank you!!!
Reference
 General Practice John Murtagh
 The Hong Kong Practitioner
Vol. 23 no. 2 “Food induced asthma attacks in children”
Vol. 23 no. 6 “Avoiding pitfalls in the management of epilepsy”
 The latest COPD guideline in http://ha.home/visitor