1. P RACTICAL ISSUES IN L ONG T REM M ANAGEMENT OF A STHMA DESPITE REGULAR FOLLOW UP Dr kondekar Santosh TN Medical college Mumbai Writetodoctor@gmail.com www.breathingdiary.com text 9869405747 for questions 1

2. COMPLIANCE Patient doesnt agree with diagnosis of asthma Patient doesnot want to use inhaler Mdi complex Not compliant with timely dose and technique Doesnt want to use two inhalers Doesnt chart symptom diary 2 www.breathingdiary.com text 9869405747 for questions

3. COMPLIANCE Patient doesnt agree with diagnosis of asthma Structured education with models, and response to bronchodilator Patient doesnot want to use inhaler Mdi complex Explaining how the dose via MDI is too small compared to oral or Neb. HELP THEM CHOOSE THE DEVICE. Not compliant with timely dose and technique Preparing a convenient time schedule sitting together Doesnt want to use two inhalers Explain the need, SMART therapy, Doesnt chart symptom diary Make diary short simple taking seconds to chart 3 www.breathingdiary.com text 9869405747 for questions

4. EXACERBATIONS Gets frequent exacerbations Gets exacerbations every season Gets exacerbations every three months Doesnt use rescue medicines Often gets hospitalised with each exacerbation Often asks for nebulisation from local dr 4 www.breathingdiary.com text 9869405747 for questions

5. EXACERBATIONS Gets frequent exacerbations Common reasons are low dose, wrong technique and exposure to allergen Gets exacerbations every season Teach them season wise step up step down, if possible with Peak flow meter Gets exacerbations every three months Often related to inhaler getting empty Doesnt use rescue medicines Tech them not to reserve it for serious episodes alone. The treatment is control based. Often gets hospitalised with each exacerbation Need to make them manage exacerbations at home with confidence, with teaching them when to rush to dr. Explain Control based Therapy and step up step down principles. Often asks for nebulisation from local dr Delayed rescue medicine makes it less effective. Teach them timely rescue medicine, and how neb may harm at times PRESCRIBE A WRITTEN SELF MANAGEMENT PLAN (GINA) 5 www.breathingdiary.com text 9869405747 for questions

6. A CTIVITY Restricts sports School absenteesm Exercises? 6 www.breathingdiary.com text 9869405747 for questions

7. A CTIVITY Restricts sports What and why not to be restricted? How does an asthmatic gain full activity potential? School absenteesm Training school and parents about rescue medicine Frequent unintended activity restrictions may need steroid raise Exercises? Breathing exercises? Will help UACS? 7 www.breathingdiary.com text 9869405747 for questions

8. D IFFICULT OR REFRACTORY ASTHMA Suboptimal response despite regular therapy Gets frequent febrile episodes Requires daily rescue medicines Sleepless nights Poor QOL Missed comorbidities AR Adenoid GER PND Possible change of diagnosis/evaluations ? 8 www.breathingdiary.com text 9869405747 for questions

9. D IFFICULT OR REFRACTORY ASTHMA Suboptimal response despite regular therapy Check dose duration technique and spacer cleaning, may need steroid raise and allergen lookout Gets frequent febrile episodes# Comorbid- sinus, adenoid tonsil? Or TB? Requires daily rescue medicines Check steroid inhaler canister empty ? Or needs higher doses Sleepless nights A serious need to reorganise treatment plan with SMART Poor QOL Suggests second look at the case and replan from diagnosis to management Missed comorbidities AR Adenoid GER PND Possible change of diagnosis/evaluations ? CLD? 9 www.breathingdiary.com text 9869405747 for questions

10. W HATS NEW IN GINA GUIDELINES 2015 1. Tiotropium that was a option available in past is now included in step 4 and 5 as add on drug as a major controller medicine... In addition to LABA LTRA and immunotherapy. Not in children below age 18yr as no studies.. Except as emergency. 2.Separate flow chart for preschooler asthma exacerbation added when in a diagnosed asthma with an exacerbation, oral steroid can be started within two hours of 3 salbutamol inhalations needed for wheezing. 3. Breathing techniques will now be considered exercises and will be shifted to low level evidence from A to B 4.In pregnancy SABA and regular controller not contraindicated. Babies of mothers on SABA perinatally should be watched for neonatal hypoglycemia. 5.GiNA has taken cognizance of asthma COPD complex and cardio selective beta blockers are not absolutely contraindicated and SABA more than 200 doses a month can be a killer. 6. Need for low dose steroid continuation to be reassessed every three monthly. 10 www.breathingdiary.com text 9869405747 for questions

11. U NDER 6 YR KIDS Any of the following features suggest an alternative diagnosis and indicate the need for further investigations or referral Failure to thrive Neonatal or very early onset of symptoms (especially if associated with failure to thrive) Vomiting associated with respiratory symptoms Continuous wheezing Failure to respond to asthma controller medications Symptoms not associated with typical triggers, such as colds Focal lung or cardiovascular signs, or finger clubbing Hypoxemia outside context of viral illness 11 www.breathingdiary.com text 9869405747 for questions

12. W HATS NEW IN GINA THEMES You Can Control Your Asthma For parents/patients: Learn Educate Have a written Plan Understand rescue, step up down and Control based therapy 12 www.breathingdiary.com text 9869405747 for questions

13. THANK YOU For doubts and questions writetodoctor@gmail.com Or text at 91-9869405747 13 www.breathingdiary.com text 9869405747 for questions