Dr Raju Final- Bhandup

8/8/2019 Dr Raju Final- Bhandup

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Dr S Raju



Asthma is a common disorder◦ It can happen to anybody◦ It is not contagious◦

It produces recurrent attacks of coughwith or without wheeze

◦ It can be effectively treated◦ Between attacks people with asthma

lead normal lives as anyone else◦ In most cases there is some history of

allergy in the family



Most patients with asthma aretreated by primary carephysicians (>60%).

Some asthmatics havemanagement problems that

should be referred to a specialistin asthma.



15 – 20 million asthmatics in India In Delhi prevalence estimated at 12% in

children

Significant cause of school/ workabsence

Increasing morbidity and mortality



More than one of the symptoms e:g : wheeze,cough, difficulty breathing, chest tightnessespecially if ◦ Frequent and recurrent◦ Worse at night and early morning

◦ Occur in response to, or worse after Exercise or other trigger – eg exposure to pets, cold ordamp air, emotions or laughter

◦ Occur apart from colds Personal history of atopic disorder

Family history of atopic disorder and/or asthma Widespread wheeze heard on auscultation History of improvement in symptoms or lung

function in response to adequate therapy



Symptoms with cold only, no interval symptoms Isolated cough in absence of wheeze or

difficulty breathing

History of moist cough Repeatedly normal chest examination whilst

symptomatic Normal PEF or spirometry whilst symptomatic

No response to trial of asthma treatment Clinical features pointing to alternative

diagnosis



Prevention of triggers

Patient education

Pharmacological drugs

PEFR measurement



Minimal (ideally no) chronic symptoms Minimal (infrequent) exacerbations

No emergency visits

Minimal (ideally no) need for "as needed” use of β 2-

agonist No limitations on activities, including exercise

PEF circadian variation of less than 20 percent

(Near) normal PEF/FEV1

Minimal (or no adverse effects from medicine)



"The aim of asthmamanagement should be

control of the disease"





Gain control as quickly as possible; then

decrease treatment to the least medicationnecessary to maintain control. Gainingcontrol may be accomplished by either starting treatment at the step most appropriate to the initial severity of thecondition or starting at a higher level of therapy (e.g., a course of systemiccorticosteroids or higher dose of inhaled corticosteroids) and then stepping down



Review treatment every 1-6 months; agradual stepwise reduction intreatment may be possible.

If control is not maintained, considerstep up.



At each step, patients should control their environment to avoid or control factors

that make their asthma worse (e.g.,allergens, irritants); this requires specificdiagnosis and education.



Step down◦ Review treatment every 1-6 months.

◦ If control is sustained for at least 3 months, agradual stepwise reduction in treatment may be

possible Step up

◦ If control is not achieved, consider step up.

◦ But first, review patient medication technique,adherence and environmental control (avoidance of

allergens or other precipitant factors)



The stepwise approach presents guidelinesto assist clinical decision-making.

Asthma is highly variable; clinicians shouldtailor specific medication plans to the needsand circumstances of individual patients



Asthma management in 2007 is focused on control of the individual patient’s asthma symptoms, aparadigm shift from earlier recommendations of astep-wise increase in therapy based on asthmaseverity;

Patient self-management plans play an important rolein prevention of exacerbations;

Successful asthma interventions lead to increasedmedication costs but decreased costs forhospitalization, and decreased death rates;

Allergen exposure is an important contributory factorin exacerbations of IgE-mediated asthma.



Allergens

Tobacco smokeIndoor pollutants and irritants



Animal dander◦ Remove animal from house / keep animal out of patient’s bedroom

House dust mite◦ Encase mattresses in an allergen-impermeable cover

◦ Wash sheets and blankets in hot water weekly◦ Remove carpets from bedroom / avoid sleeping on upholstered furniture

Cockroaches◦ Poison baits / Do not leave food and garbage exposed

Indoor mould◦ Fix all leaks and eliminate water sources associated with mould growth

◦ Clean moldy surfaces

Pollen◦ Stay indoors esp. in the afternoons◦ Windows closed during the season in which they have problems with outdoor allergens



Stop smoking or smoke outside home (patients andothers at home)

Smoking reduces the response to inhaled steroid Daycare providers / workplace smoke

Reduce wood-burning stoves and fire-places Unvented stoves and heaters Reduce perfumes / cleaning agents / sprays

etc.



Quick Relief Preventive (controller)• Short-acting β2-agonist

• Salbutamol• Terbutaline

• Anticholinergics• Ipratropium Bromide• Tiotropium bromide• Short-acting theophylline• Aminophylline• Doxophylline•

Adrenaline injections

• Inhaled Corticosteroids• Beclomethasone• Budesonide• Fluticasone

• Ciclesonide• Leukotriene modifiers

Montelukast• Long-acting bronchodilators

• Salmeterol (inhaled)•

Formoterol (inhaled)• SA salbutamol (oral)• SR theophyllines (oral)



GINA Workshop Report,2003



If a patient uses◦ b

2agonists > twice per week in day time,

◦ or awakens > twice per month with nocturnalasthma,

◦ or refills a b2-inhaler > twice in a year, then the patient's asthma is mild

persistent or greater and daily anti-inflammatory therapy is required.



GINA Workshop Report,2003



Inhaled steroid



Inhaled corticosteroids Budesonide/ beclomethasone/

fluticasone/ ciclesonide – use any

Start (400-1000 mcg/day approx. in 2divided doses)

Maintain for 2 to 3 months

Taper slowly Safe for long-term use (years)



Most potent anti-inflammatorymedications for asthma

Prevent decline in lung function

Safer than other equally effectivetreatments

Most cost-effective



Throat infections (gargle/ use spacer)Hoarseness (singers/teachers/ leastwith ciclesonide)

Cataracts?Osteoporosis?



Same dose for at least 3 months Then, gradual stepwise reduction intreatment (25% - 50% every 1 - 3

months)Use peak flow meter – very imp



New EU scale



No symptomsAsymptomatic during exercise andplay

Sleep undisturbedMinimal / no use of ‘relief’medication



~ 400 mcg/day (budesonide) Over 9 years of continuous use No growth retardation Uncontrolled asthma causes growthretardation

Pedersen and Agertoft NEJM 2000;343:1064-69



Non-compliance / non-adherenceHabitual b2-agonist overuseGE refluxSinusitisHyperventilationOthers:

◦ Bronchiectasis /PE◦ OSA /Cardiac disease



first reconfirm diagnosis

Check Inhaler Technique /

Check RegularUse

Add LABA

Formoterol /

Salmeterol

Increase doseof inhaled

steroid

AddLeukotriene

modifier

Add SR Theophylline



First-line add-on therapy at Step 3(BTS)

But over a 4-fold dosage range (200-

800 mcg BDP/BUD)So the dilemma is at what dose toadd the LABA ?



80-90 % of the maximum therapeuticbenefit of ICS is achieved at daily doseof 200mcg FP or 400mcg BUD

200 mcg FP or equivalent shouldbe the preferred dose at which toconsider adding LABA if control is

inadequate Masoli M et al, Thorax 2005;60:730-734



PrednisoloneAcute severe episodesDispense preferablySteroid-dependent asthma (regularneed)



Montelukast 10mg/day (5mg/4mg forchildren)

Oral anti-inflammatory

Not as effective as inhaled steroid First-line option for 2 to 5 yr. olds in

mild persistent asthma

All your ‘regular’ bronchodilator users



As an add-on agent at every step of persistent asthma

As an option particularly in children < 5years with mild persistent asthma

When patients strongly resist takinginhalation medication in spite of adequatetraining and counseling

Exercise-induced asthma Aspirin-sensitive asthma Allergic rhinitis and asthma



Sustained release for regular use Inexpensive , but toxicNot more than 400 mg per day

(serum levels 1 – 5 mcg/ml)Anti-inflammatory effects



Long acting Beta²-agonist (LABA) Montelukast SR Theophylline



Non-pharmacological methods-insufficient evidence (Acupuncture,Homeopathy, Immunotherapy)

Breast feeding, smoking cessation,weight control for obesityrecommended

Role of non-static spacersAction plans



Monotherapy with cromones is nolonger given as an alternative tomonotherapy with a low dose of ICS

in adults. Long-acting beta-2-agonists likebambuterol are no longer

recommended as add-on agents insevere asthma.





Patients still suffer poor asthma control despite beingprescribed regular ICS or ICS/LABA treatment

Patients recognize impending worsening and managethese spontaneously by increasing their medication, butin a sub-optimal way

The time from early warning signs and the peak of aworsening provides a window of opportunity for betterself-management to reduce and prevent symptoms andexacerbations

There is a clear need of awareness at the level of both thephysician and patient to effectively control asthma





Base: all respondents (n=3,415)

Patients (%)

0 10 20 30 40

9+

5-8

3-4

1-2

None

Number

ofinhala t

ions/day



Proportion of patients reporting disease ‘relatively good’ in thepast week:

Relatively good

96%96%

87%87%

55%55%

Well-controlled by

ACQ

Not well-controlled by ACQ

Uncontrolled by ACQ

Relativel

y good

Relatively good

Patridge MR et al,BMC Pulmonary Medicine 2006,



Respiratory Medicine Vol 96 (2002) 835-840



Respir Med 2002; 96: 835-40



Fear about steroids Do not like public labeling as asthmatic Fear of addiction

Feel pumps reserved for serious orsevere attacks or will fail to act

Misconception that costly Prefer oral medications Physicians lack of knowledge and time



A new approach to asthma management



ICS plus LABA for prophylaxis and relief Simple one device treatment strategy Improves daily control

Prevents severe exacerbations moreeffectively than higher dose ICS plusSABA or maintenance ICS/LABA plusSABA reliever

Recommended in recent GINAguidelines



Control-drivenmanagement

“to achieve and maintaincontrol”

“Treating to target”

Not wellcontrolled

Partly controlled

Controlled



The goal of management is CONTROL of asthma

Current Clinical Control and controlling

Future Risk Addressing OBSTACLES to asthma

control Better use of CURRENT TREATMENTS



Develop a doctor / patient partnership

Doctor-directed patient self-Doctor-directed patient self-

managementmanagement



Single inhaler for relief andmaintenance

Regular maintenance dose (usually

twice daily) with additional inhalation(s)as needed Patients do not require a separate SABA Use of reliever is always accompanied

by an extra dose of anti-inflammatoryICS



Single maintenance and relief therapy For better informed and less compliant

patients Not for poor perceivers of worsening Home PEFR use preferred Patient directed rather than physician

controlled (now proven to be effective in

over 6 studies)



A highly effective way of stepping up anti-inflammatory therapy in line with disease activity

If a combination inhaler containing formoterol and budesonide is selected, it may be used for

both rescue and maintenance. This approach hasbeen shown to result in reductions inexacerbations and improvements in asthmacontrol in adults and adolescents at relatively lowdoses of treatment (Evidence A )



Emphasizes Asthma management on◦ Clinical control rather than classification of

patient by severity

Exacerbation◦ One of the important criteria in assessing

asthma control

This important shift reflects in

pharmacological care asthma includingnew treatment approach



Treats the underlying inflammation with

every inhalation

Reduces exacerbations

Improves daily asthma control

Reduces overall steroid load

Is simple to use with only one inhaler formaintenance and relief

1O’Byrne PM, et al. Am J Respir Crit Care Med 2005;171:129–136; 2Rabe KF, et al. Lancet2006;368:744–753;

3Vogelmeier C, et al. Eur Respir J 2005;26:819–828; 4Rabe KF, et al. Chest2006;129:246–256;

5Scicchitano R, et al. Curr Med Res Opin 2004;20:1403–1418; 6Kuna P, et al. Int J ClinPract 2007;In Press.



One or more present:◦ Use of accessory muscles of respiration

◦ Pulses' paradoxicas >25 mm Hg

◦

Pulse > 110 pm◦ Inability to speak sentences

◦ Respiratory rate >25 - 30 breaths/min

◦ PEFR or FEV1 < 50% predicted

◦ SaO2 < 91- 92%

McFadden Am J Respir Crit CareMed 2003



Tachypnea Tachycardia Wheeze Hyperinflation Accessory muscle use Pulses paradoxicus Diaphoresis (profuse sweating)

Cyanosis Obtundation (altered mental state)

Brenner, Tyndall and Crain In: Emergency Asthma. MarcelDekker 1999



Previous episode of near-fatal asthma Multiple prior ER visits or hospitalizations Poor compliance with medical treatments Adolescents or inner city asthmatics Recent use of oral corticosteroid (OCS) Inadequate therapy:

◦ Excessive use of β-agonists

◦

No inhaled corticosteroid (ICS)◦ Concomitant β-blockers

Ramirez and Lockey In: Asthma, American College of

Physicians, 2002



Lower or upper respiratory infections Cessation or reduction of medication Concomitant medication, e.g. β-blocker Allergen or pollutant exposure





Respiratory frequency: (count)◦ Speech: sentences, single words

Auxiliary respiratory muscle use Posture: sitting, can patient lie down? Airway patency: rhonchi, silent chest (PEF) Respiration: cyanosis (SaO2, blood gases) General appearance, effort of breathing:

activity level (pulse rate)



Oral corticosteroids are the most powerfulmedications available to reduce airwayinflammation

Use until attack has completely abated:◦ PEFR and FEV1 at baseline levels

◦ Symptoms gone

Taper to QOD and determine if patient canremain well if corticosteroids are withdrawncompletely



Treat the condition symptomatically Determine what caused the exacerbation:

◦ inhalant allergen

◦ food allergen

◦ drug reaction (ASA, vaccination, etc)◦ infection

◦ worsening of a chronic condition:

◦ poor therapy compliance

Treatment needs adjustment



Use antibiotics if any suspicion of bacterial infection

If antibiotics are prescribed,recommendation is for broad spectrummacrolide antibiotics that cover atypicalbacteria (chlamydia, mycoplasma), eg,azithromycin, clarithromycin,

erythromycin, roxithromycin,dirithromycin, amoxicillin + clavulan;moxifloxacin, cefuroxin



IS A RESPIRATORY ATTACK! Consider improved prophylaxis:

◦ Treat, Monitor and Follow-up allergen avoidance

allergen vaccination

pharmacological treatment update

stop smoking

enhance compliance to recommendations

teaching and monitoring



Seasonal asthma◦ Use same stepwise approach as for the long-term

management of asthma.

◦ Begin anti-inflammatory agents two weeks prior

to the anticipated onset of the season andcontinue through the season.



Seen more in young children. Use same stepwise approach as for the

long-term management of asthma.

Chronic use of anticholinergics for thisdisorder is not recommended



Poorly controlled asthma duringpregnancy results in increasedperinatal mortality; increasedprematurity and low birth weight

Controlling the mother's asthma withthe use of bronchodilators and anti-inflammatory medication is best for the

baby and mother



Surgical patients receiving systemiccorticosteroids during the last 6 months

Give 100 mg hydrocortisone q 8 h i.v.

during the surgical period and reducedose rapidly 24 h following surgery



Missing cardiac asthma and treating itas bronchial asthma

Missing near fatal asthma cases

Misdiagnosing the severity of asthma Not giving inhaled steroid to patients

with persistent asthma Not differentiating between asthma and

COPD



Buying a Peak Flow Meter (severity of asthma,diagnosis of asthma, drug titration, aggravatingfactors, diagnosing exercise induced asthma,personal best parameter: chargeable test)

FEV1 test: small machine gives the FEV1 and canbe billed as mini spirometry

Asthma group counseling sessions can be charged



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Dr Raju Final- Bhandup