1. COMMON ERRORS IN MANAGEMENT OF BRONCHIAL ASTHMA IN A PERIPHERAL HOSPITAL Surgeon Cdr Anuj Singhal Graded Specialist (Med)

3. Introduction Airway diseases is a leading cause of disability and mortality There is airflow limitation and inflammation with progressive decline in respiratory function and quality of life. Bronchodilators slows the rate of decline in lung function and reduces frequency of exacerbations. Reduces financial and personal burden. Spirometry is the gold standard for demonstrating and assessment of severity, reversibility of disease and response to treatment of airway disease Optimizing Management of COPD in the upcoming decade. International Journal of COPD 2011:6, 47-61

4. Introduction In absence of spirometry symptom free patients not having an exacerbation in a year is considered to have an adequate response. Standard treatment of: a) Bronchial Asthma Salmetrol (25 mcg) Fluticasone (250 mcg) 2 puff BD Salbutamol (100 mcg) 2 puff QID + SOS b) COPD Ipratropium (20 mcg) + Salbutamol (100 mcg) 2 puff TDS + SOS Tiotropium (9 mcg) 2 puff BD In this study we have tried to identify the sub clinical non responders to medicines and to identify the common errors in their management GINA report,Global Strategy for Asthma Management and Presentation 2008 and National Asthma and Presentation Programme. Expert panel report 3,2007

5. Aims and Objectives To detect common errors in management of Bronchial Asthma. To detect sub clinical non responders to standard protocols. To assess the need for Spirometry as follow up tool for treatment of airway disease

6. Materials and Methods All patients attending the Bronchial Asthma/ COPD clinic at 9 AFH since last 2 years were considered. Inclusion Criteria Patients on regular treatment at 9 AFH for minimum 1 year. Exclusion Criteria Smokers Patients with lung pathology- bronchiectasis, Pleural disease, active or healed Pulmonary tuberculosis, Lung malignancies Who had exacerbation in the last 1year

7. Methodology Details of symptomatology, duration of disease and treatment were noted. Clinical examination was done Investigations- Hemoglobin, total leukocyte count, absolute eosinophil count and chest X ray was performed. The standard treatment offered for Bronchial Asthma : MDI Salmetrol and Fluticasone with MDI Salbutamol COPD : Salbutamol + Ipravent, with Tiotropium.

8. Methodology Assessed by spirometery ( Medical Indian Research Spiro Lab Version 3 ) and testing techniques that followed European Thoracic Society recommendations. The higher of 3 values for FEV1 repeatable with in 100ml were recorded % of predicted values were calculated based on adult North Indian values. Reversibility was defined as An increase in FEV1 by 12% or more Absolute value at least by 200ml or more, after inhalation of salbutamol

9. Results A total of 31 patients were included 22 - Asthmatic 09 - COPD Demographic data - 21 Males and 10 Females Clinical assessment and lab reports were normal. All 31 patients have normal chest radiograph. On spirometry 5 patients had a significant increase in FEF 25-75 % values after bronchodilators.

10. Results In this study we had 16.66 % of our patients not responding to standard protocol. The most common problem we had encountered during critical analysis of our patients were: Synchronized inhalation with MDI was lacking. Paramedical personal knowledge towards MDI limited. Patients were not given clear instructions. Poor respiratory effort by patients

11. Discussion Spirometry plays a key role in patients presenting symptoms suggesting of Chronic Respiratory Disease Further where clinical profile and examination is confusing, spirometry is diagnostic. Spirometry that is performed and interpreted properly is a critical step in the accurate diagnosis. Any decline in FEF 25-75 values favor a diagnosis of Bronchial Asthma as the disease typically involves mid airway In COPD which involves terminal airway, has normal FEF 25-75 Effect of primary case spirometry on the diagnosis and Management of COPD. European Respiratory Journal 2006,28 : 945-952.

12. Discussion There are limited drugs with many delivery devices. This includes metered-dose inhaler (MDI), breath actuated MDIs, nebulizers and different models of dry powder inhalers The multiple inhalers causes confusion and increases error in patient use.

13. Devices for treatment of airway disease

14. Current delivery platforms MDI: Spacers Static and non-static Valved and non-valved With mask Dry powder Inhalers: Single dose Multi- dose Unit dose Reservoir Nebulizers: acute conditions and children Jet Ultrasonic Battery operated

15. Are all inhaler devices similar in efficacy? Chest 2005; 127:335-71 No real difference between various inhaler devices Use the cheapest (MDI)

16. Steps in using the MDI Remove cap Shake the inhaler Hold inhaler upright Tilt head slightly back Close lips around inhaler Begin to breathe in and activate inhaler Inhale slowly and deeply Hold breath for 10 seconds Use one puff Breathe out through the nose Wait 30 seconds before taking another puff Can Med Ass J 1979;120:813-6

17. 60-80% 10-20% Fate of Inhaled drugs Absorption from lung

18. Errors in MDI use At least 20 studies with > 3600 patients Incidence of misuse:12-89% (mean: 38%) Common errors Coordination of actuation and inhalation Short breath hold Rapid inspiration Inadequate or no shaking of inhaler Abrupt discontinuation of inspiration (cold freon effect) Young and old Occasional vs regular JACI 1995;96:278-83

19. Discussion Problem with MDIs Failure to coordinate inhalation with actuation of MDI, ie inadequate breath holding and inappropriate flow of drug. Lack of a dose counter- the number of remaining doses. Lack of knowledge of correct use among healthcare professionals. Elderly patients - mental state scores, hand strength and ideomotor dyspraxia. J. Allergy and Clini immunology. Improper patient techniques with metered dose inhalers: clinical consequences and solution to misuse Vol 96: 278-283

20. Discussion Combining MDI with a spacer Holding chambers and spacers reduces the need for inhalation actuation coordination with MDI use. Problems with a spacer and MDI Delay between MDI actuation and inhalation Rapid inspiration Chamber electrostatic charge Firing multiple puffs into the chamber These reduce the availability of inhaled drug. J. Allergy and Clini immunology. Improper patient techniques with metered dose inhalers: clinical consequences and solution to misuse Vol 96: 278-283

21. DPIs Introduced in the 1960s In India in the 1980s No propellants Breath actuated delivery Patient’s own inspiratory effort At least 10 types are available and 30 more in nascent stage Capsules, blisters, reservoirs and replaceable reservoirs

22. Discussion DPI is a breath actuated device No need of inhalation - actuation synchrony. The main problem is loading and priming the DPI for use. Every DPI model in current use is different Medical personnel's knowledge of correct DPI use has also been shown to be lacking Humidity reduces DPI dose effect. Practical problems with Aerosol Therapy in COPD. Respiratory Care Feb 2006 VOL 51 No-2,158-172

23. Pros and Cons of DPI Easier to use than MDI Breath actuated Single or multi-dose Compact No propellants required Lower initial cost Inspiratory flow dependent Older patients Severe COPD Acute attacks Not for all age groups Some need loading More expensive (per day) Moisture sensitive Dose lost if patient exhales into device

24. Any others?? Bunching together the benefits of MDI and DPI

25. What are BAIs? MDI Patient’s inhalation through the device triggers a mechanism that fires the MDI Firing and inhalation are automatically coordinated Autohaler™

27. Press & Breath inhaler poor coordination Autohaler™ Inhalation Device same patient 20.8% 7.2% Drug Deposition with the Autohaler™ Inhalation Device MEAN Lung Deposition Newman SP, Weisz AW, Talaee N, et al. Improvement of drug delivery with a breath actuated pressurized aerosol for patients with poor inhaler technique. Thorax. 1991; 46(10):712-716

28. Autohaler improves lung deposition in poor coordinators Thorax. 1991; 46(10):712-716

29. Discussion Breath activated MDI do not requires synchronization with the patients breathing It is easy to use. Requires minimum inspiratory flow (272/ min) for activation for better synchronization. It can be used by all adults and children with severe air flow obstruction for better asthma control Improvement of Asthma Control With A Breath Activated Pressurized Metered Dose Inhaler (BAI) A Prescribing Study of 5556 patients using traditional pressurized MDI or a BAI. Respiratory Medicine 2003. Vol 97, 12-19.

30. Possible errors/difficulties in the use of BAI Device related Difficulty in removing the cap Failure to lift the lever Holding the BAI upside down Not replacing the cap Device unrelated Failure to exhale completely before breathing in. Failure to breathe in deeply and slowly Failure to hold breath for 10 seconds. Breathing in through the nose.

31. MDI with no coordination needed Preferred by patients among various inhaler devices Activated by flow rates as low as 20-30 l/min Can be used by all Adults and children Severe airflow obstruction Acute attacks Improve asthma control BAI: Key highlights Improvement of Asthma Control With A Breath Activated Pressurized Metered Dose Inhaler (BAI) A Prescribing Study of 5556 patients using traditional pressurized MDI or a BAI. Respiratory Medicine 2003. Vol 97, 12-19

32. Discussion In this study 16.66 % patients did not respond to standard protocol. The most common problem we had encountered during critical analysis of our patients were: Synchronized inhalation with MDI was lacking. Paramedical personal knowledge towards MDI was limited. Patients were not given clear instructions. Poor respiratory effort by patients. In other studies up to 38% patients were found to have improper utilization of MDI. These problems were related to improper training and limited knowledge in usage of MDI. We had trained our nursing staff and patients in using a MDI Supplemented MDI with a spacer to patients in those who were having poor coordination with MDI / DPI. Mcfadden ER,Jour of Allergy and Clini immunology, Improper patient techniques with metered dose inhalers: clinical consequences and solution to misuse Vol 96: 278-283

33. Comparison of 7 devices: Assessment of use in 100 patients Resp Med 2000;94:496-500

34. Discussion Asthma severity as determined by the Global initiate for Asthma classification is significantly associated with symptoms, limitations in normal daily activities, asthma related medical resource utilization and both direct and indirect costs Therefore prescribing expensive devices to patients like auto halers / BAI’s may be considered only after exhausting simple, cheaper and effective devices like spacer Asthma Severity and Medical Resource Utilization European Respiratory Journal 2004,23:723-729

35. Conclusion Commonest error in management is mismatch of MDI use with patient respiratory effort but by educating patient it can be minimized. Further by using spacer with MDI is as good as novel devices like BAI. Spirometry should be used early to differentiate Bronchial Asthma/COPD cases for better diagnosis. Even in the absence of spirometry, asthma management is good in a peripheral setup.

36. Take home message Prescribing expensive devices to patients like auto halers / BAI’s may be considered only after exhausting simple, cheaper and effective devices like combining spacer with MDI.