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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