Bronchial Asthma
An Overview – Based on
GINA Management Guide Lines
Dr. R.V.S.N. Sarma, M.D., M.Sc. (Canada),
Consultant Physician & Chest Specialist
visit us at: www.drsarma.in
1
When you can't breathe,
nothing else matters®
American
Lung Association
2
Bronchial Asthma
A Paradigm Shift In
The Management
Time Now, to Unlearn Our
Age Old Outdated Practices
3
Resources Consulted – Sincere Thanks
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GINA
ACCP
ATS
BTS
NICE
Chest Net
CDC
NAEPP
CTS
www.ginasthma.org
www.chestnet.org
www.thoracic.org
www.brit-thoracic.org.uk
www.nice.uk.org
www.chestnet.net
www.cdc.nih.gov
www.naepp.nhlbi.org
www.respiratoryguidelines.ca
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What Is Asthma ?

Primarily – Allergic inflammation of AW

Secondary – Bronchoconstriction
– Airway Hyper-reactivity - AWHR
– Recurrent wheezing, coughing and SOB
– Airflow limitation is variable and often reversible
– Infiltration of dendritic cells, mast cells,
eosinophils and lymphocytes
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The Huge Gap

Many patients are not detected

Many do not seek medical attention

Many have no access to health service

Many doctors do not do what is right

Stigma associated with the label

Broken marriages, alliances

Missed diagnosis (Bronchitis, LRI)
7
Mechanism of Asthma
Risk Factors (for development of asthma)
Innate Atopy
INFLAMMATION
AWHR
Airflow Limitation
Risk Factors
(for exacerbations)
Symptoms
(SOB, cough, wheeze)
Pathology of Asthma
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Risk Factors for Asthma
Causal Factors
 Indoor Allergens
–
–
–
–

Domestic mites
Animal Allergens
Cockroach Allergens
Fungi moulds
Outdoor Allergens
Host Factors

Contributing Factors




– Pollens
– Fungi, RSV

Occupational exposure
Genetic Atopy ( IgE), AWHR

Respiratory infections
Small size at birth, Obesity
Diet
Air pollution
– Outdoor pollutants
– Indoor pollutants
Smoking – Active / Passive
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House Dust Mite
 Use bedding encasements
 Wash bed linens weekly
 Avoid feather filled ones
 Limit stuffed toys to those
that can be washed
 Reduce humidity level
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Cockroaches
Remove as many water and food sources
as possible to avoid cockroaches. Left over
food, moisture, drains, open cupboards are
the common sources – kitchen and toilets
Don’t eat anywhere except in the dining.
12
PETS
 People allergic to pets should not
have them in the house.
 At a minimum, do not allow pets in
the bedroom.
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Molds – Fungus
Eliminating molds may help control asthma exacerbations.
14
Diagnosis of Asthma

History and patterns of symptoms

Physical examination

Measurements of lung function
– Peak flow meter
– Spirometry
15
Patient History

Recurrent attacks or episodes of wheezing?

Troublesome cough, worse particularly at night

Cough after physical activity (e.g. playing)?

H/o seasonal attacks of breathing problems.
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Main Symptom Clues

Do the patient’s colds ‘go to the chest’ or take more
than 10 days to resolve?

Does the patient use any medication ? Is there
(relief) ? (e.g. bronchodilator) when symptoms occur

If the patient answers “YES” to any of the above
questions, suspect asthma.

Remember, the commonest cause of persistent
cough is asthma
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Physical Examination



Wheeze
Usually heard without a stethoscope
Dyspnea
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
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Physical Examination

Hyper-expansion of the thorax

Increased nasal secretions or nasal
polyps

Atopic dermatitis, eczema, or other
allergic skin conditions
19
Screening Test – Peak Flow
Diagnosis of asthma can be suspected
by demonstrating the presence of airway
obstruction using Peak flow meter.
Peak Flow Meter is a
basic tool in a GPs office
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Diagnostic Test – The PFT
Diagnosis of asthma can be confirmed by demonstrating the
presence of reversible airway obstruction using Spirometry.
21
Spirometry Results

FVC
Forced Vital Capacity

FEV1
Forced Expiratory Volume
in the first second

FEV1÷FVC
Ratio of the above two

PEFR
Peak Expiratory Flow Rate

FET
Forced Expiratory Time
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Spirometry Normal Values
1.
There are no fixed ‘Normal’ values
2.
Dependent on age, sex, ht, wt, ethnicity
3.
Observed value expressed as predicted value %

FVC
Normal if > 80% of predicted

FEV1
Normal if > 80% of predicted

FEV1/FVC
At least 75%

PEFR
Normal if > 80% of predicted

FET
Less than 4 seconds
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Typical FEV1 Tracings
Volume
FEV1
Normal Subject
> 80%
Asthmatic (After Bronchodilator)
60%
Asthmatic (Before Bronchodilator)
40%
Each FEV1 curve represents
the best of three repeat efforts
1
2 3 4
Time (sec)
5
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Obstructive v/s Restrictive
Parameter
Normal
Obstructive
Restrictive
Problem
‘Air out’ and
‘Air in’ normal
Unable to
get ‘Air out’
Unable to
get ‘Air in’
FVC
80 % of pred
Normal or ↓
↓,↓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
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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 PF as close to normal as possible

Minimal (or no) side effects from medicine
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Tool Kit We Have





Relievers (Quick)
Controllers (long term)
Peak Flow meter
Spirometry
Patient education
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Asthma Treatment Today

We can completely control symptoms

Make their life as normal as possible

Treatable by general practice physicians

We do not need to be Chest Specialists!
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It is a Dual Problem
1.
Bronchial inflammation – perpetual
1. Allergic inflammation and edema
2. Inflammatory mediators – perpetuate
3. edema and excite bronchospasm
4. Bronchial hyper reactivity to triggers
2.
Bronchospasm – acute attacks
Needs two different types of medicines
Relievers & Controllers
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Certain Abbreviations








ICS
IBD
SABA
LABA
LTA
OCS
SR
Ach B
Inhaled corticosteroids
Inhaled bronchodilators
Short acting β agonists
Long acting β agonists
Leukotrine antagonists
Oral corticosteroids
Sustained release
Acetylcholine blockers
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What Are Relievers?

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
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Relievers

Rapid-acting inhaled β2-agonists
– Salbutamol, Levo Salbutamol

Anti-cholinergics
– Ipatropium, Tiotropium

Short-acting oral β2-agonists
– Salbutamol, Levo Salbutamol, Terbutaline


Systemic glucocorticosteroids (Status Asthmaticus)
Theophylline (oral) – (evidence C)
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What Are Controllers ?

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
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Let Us Question
 Are we giving the right drug?
 Are we giving the drug in right form?
 Are we using the correct technique?
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The Story Of Asthma Treatment
Normal
Inflamed (untreated)
Regular
Inhaled
Steroid
Remodeled
Partly
Treated
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Most Important
All Asthma drugs should ideally be
taken through the inhaled route.
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What Changes Their Life ?
ICS
Inhaled corticosteroids
ICS are the most potent and effective antiinflammatory medication currently
available for Asthma *
*GINA (NHLBI & WHO Workshop Report)
*Guidelines for the diagnosis and management of Asthma NIH, NHLBI
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Let Us Believe First
Corticosteroids ??
Inhaled medicines ?? Patients’ wrong belief
Parents / Grand parents
Neighbors / ‘friends’
First of all, let us believe in science
Let us explain and convince them
Let us change their lives – to happy lives
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Let Us Unlearn
 Adrenaline s/c, thank heavens we forgot !!
 Deriphyllin + Betnesol I.V - give up please - Must !!
 Oral SABA and LABA – Restrict their use !!
 Theophylline in any form beware !!
 Systemic steroids – Not at all the choice !!
ICS and IBD are the Rx.
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Remember
Instead of asthma
controlling our patient,
allow our patient to
control his / her asthma
41
Why Inhalation Treatment
Oral
Inhaled route

Slow onset of action

Rapid onset of action

Large dosage used

Less amount of drug

Greater side effects

Drug delivered to the site

Erratic absorption

Better tolerated

Not useful in acute
illness

Treatment of choice
in acute symptoms
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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)
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ICS – How safe are they?
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
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ICS are 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
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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

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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
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Leukotrine 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
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Step Up and Down – Acute Asthma
SABA (IBD) in full doses
 SABA Increase frequency or Nebulize
 SABA as above + IPA (IBD), then add
 OCS (Methyl 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 compliance
 Look for aggravating factors like
– GE Reflux, Emotions/ Stress, Sinusitis, Allergic Rhinitis
 ? Role for Theophylline; Oral SABA or LABA not very useful

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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 an add on
 SABA or LABA Oral + IPA (IBD) may be a useful add on
 No long acting steroid injections
 No injectable or short acting Theophylline

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Controlled
REDUCE
LEVEL OF CONTROL
THERAPEUTIC ACTION
Maintain and find lowest
controlling step
Consider stepping up
to gain control
Uncontrolled
Exacerbation
INCREASE
Partly controlled
Step up until controlled
Treat as exacerbation
REDUCE
STEP
1
INCREASE
TREATMENT STEPS
STEP
STEP
STEP
2
3
4
STEP
5
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Why doctors don’t use inhalation Rx ?

Status quo – No mood to unlearn

“My practice is good or ‘great’

Oral therapy is easy

Too busy

Difficulty in convincing

Cost (in fact, in the long run economical)

Headache to explain
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Drug Delivery Options

Metered dose inhalers (MDI)

Dry powder inhalers (Rota haler)

Dry powder compressed for Disc haler

Spacers / Holding chambers

Nebulizers
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Demonstration of the correct technique
Ask the patient to demonstrate
to you the technique
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Drug Delivery - Options
1. Dexterity

pMDI – Metered Dose Inhalers
2. Hand grip strength

Rota halers, Disk halers
3. Co-ordination

Space halers
4. Severity of ROAD

Zerostats
5. Educational level

Nebulizers
6. Age of the patient

Oxygen mixed delivery

Oral tablets, syrups

Parenteral – I.M or I.V use
7. Ability to inhale and
synchronize
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What Drug Delivery Method ?







Very young or very old
MDI + LV Spacer
Elderly
MDI + SV spacer
Young children > 7 yrs
DPI (Rota haler)
Adults - educated
MDI alone
Adults - no co-ordination
DPI (Rota haler)
Clinic setting
MDI + Spacer
Clinic - emergency
Nebulizer
Choice is to be individualized; Trial and error
may be needed; Cost may be a factor
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Inhalation Devices
Rotahaler
Dry powder Inhaler
Metered dose
inhaler or MDI
Spacer
Space halers
58
MDI + Large Volume Spacer
59
The Zerostat Advantage
1.
Non-static spacer made up of polyamide material
2.
Increased respirable fraction; Increased deposition of
drug in the airways
3.
Increased aerosol half-life; Plenty of time for the patient
to inhale after actuation of the drug
4.
No valve; No dead space; Less wastage of the drug
5.
Small, portable, easy to carry, child friendly
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Disk haler – Nebulizer
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Nebulizer Therapy
1.
Severe breathlessness despite using inhalers
2.
Assessment should be done for improvement
3.
Choice between a facemask or mouth piece
4.
Equipment servicing and support are essential
5.
0.5 ml of Ipa + 0.5 ml of Sal + 5 ml of Nacl (not DW)
6.
If decided to use ICS (FEV1 < 50%) - 0.5 ml of Buduso.
7.
15 minutes and slow or moderate flow rate
8.
Can be repeated 2 to 3 times a day – Mouth Wash
62
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
63
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

In most cases, there is some family history of allergy
64
Patient Education

Can be effectively controlled, although can’t 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.
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Yours Faithfully Urges

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
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Life Time Happiness
Can we dare to make
them pulmonary invalids ?
Let Us Give Them
Life Time Happiness
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