1. Asthma: In my practice
Bangladesh
Dr GM Monsur Habib

2. Bangladesh Demographic Profile 2014-15
Area: sq km
Population:
Asthma Prevalence: 6.9%
Total Asthmatics in Bangladesh: 11,473,000
Asthmatics in Practice Zone: 2,551,958
Catchment area of my practice: Km2

3. 1505-1520: In Bangladesh, Dr Monsur Habib
My Practice software

4. Reception & Registration
Basic Data Collection
My Practice Protocol
Two Shift Practice:
Morning
Evening
Counseling Room
Waiting area
Video/Poster
Consultation Room
Prescription
Lung Function Test

5. Recording Personal Data in the practice software
Reception and Registration
Recording Personal Data in the practice software
Preparing file with patient demographics:
Weight & Height
PEF by Peak Flow meter
PIF by In-Check Dial
BP, RR, Pulse, Temperature & SpO2
ACT (for follow-up patients)
SGRQ (If asked by physician)

6. Video and poster display on Asthma/COPD
Aim: To improve health literacy & tuned

7. Initial Diagnosis of Asthma in my practice:
Variable symptoms + Variable airflow limitation
(History) (Objective Tests)
Conventional
Asthma specific History taking,
Physical Examination
Development of a trust by listening the concerns of patient and assuring to deliver the best possible service
Determine the probability of Asthma and perform objective tests
Consultation Room

8. Visit to visit variation
History suggest asthma
ICS Trial 4 weeks
Visit to visit variation
Test for variable Airflow limitation
Measure FEV1/PEFR
<80% predicted or Wheezing
>80% predicted & No Wheezing
Serial Peak Flow No
Yes
Do Reversibility Test No
Do Exercise challenge Test
Yes No
Yes
Do Steroid Reversibility Test
Asthma
Asthma
Consider other Diagnosis No
Yes

9. Spirometry by Trained coach
Reversibility test:
Pre: 1.65 L (FEV1)
Post: 2.69 L (FEV1)
Reversed by:1004 ml & 63%
After 5 mg salbutamol therapy by nebulizer

10. Diagnostic difficulties
Patterns of childhood asthma
Asthma in children
Diagnosis in children
Clinical features that increase the probability of asthma
Typical symptom pattern
Personal History of Atopic Diseases (AD)
Family history of AD or Asthma
Widespread wheeze
Response to Asthma Therapy
High probability of asthma – diagnosis of asthma is likely
Start a trial of treatment
Review and assess response
Reserve further testing for those with poor response.
Under 5’s can’t blow reliably
Many illnesses mimic Asthma
Diagnostic difficulties

11. Combination of Sx & presence of AD or parental H/O asthma
Combination of Sx & presence of AD or parental H/O asthma plus positive therapeutic trial with ICS
Combination of Sx & presence of AD or parental H/O asthma
Single or few Sx
Healthy or other diseases
Asthma
Ref: Pedersen S. Preschool asthma – not easy to diagnose. Prim Care Resp J 2007;16(1):4-6.

12. Is it occupational Asthma?
Children are not out of occupational risk.
Working in the Bidi factory
We ask about workplace exposure
Is it occupational Asthma?

13. Assessment of Asthma
Day-time Sx
Night-time Sx
Need of reliever
Activity limitation
Poor cntr.
Symptom Control
Part cntr.
Well cntr.
Risk estimation
FEV1
medication side-effects,
history of ≥1 exacerbations in 12 mo
poor adherence,
incorrect inhaler technique,
smoking, and
blood eosinophilia.

14. Pharmaco-therapy of Asthma
Standard Therapy
For poor patients
Diagnosis
Symptom control & risk factors (including lung function)
Inhaler technique & adherence
Patient preference
We prefer Economic Schedule with SMART therapy and Rescue Oral Steroid as per need
REVIEW RESPONSE
ASSESS
ADJUST TREATMENT
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
STEP 5
STEP 4
Refer for add-on treatment
e.g.
tiotropium,* omalizumab, mepolizumab*
STEP 3
PREFERRED CONTROLLER CHOICE
STEP 1
STEP 2
If rescue needs more than twice a year:
Provide add on therapy:
Montelukast
Theophylline
Med/high ICS/LABA
Low dose ICS/LABA**
Low dose ICS
Other controller options
Consider low dose ICS
Leukotriene receptor antagonists (LTRA)
Low dose theophylline*
Med/high dose ICS
Low dose ICS+LTRA
(or + theoph*)
Add tiotropium*
High dose ICS + LTRA (or + theoph*)
Add low dose OCS
As-needed short-acting beta2-agonist (SABA)
As-needed SABA or low dose ICS/formoterol#
RELIEVER
• Provide guided self-management education (self-monitoring + written action plan + regular review)
• Treat modifiable risk factors and comorbidities, e.g. smoking, obesity, anxiety
• Advise about non-pharmacological therapies and strategies e.g. physical activity, weight loss, avoidance of sensitizers where appropriate
• Consider stepping up if … uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler technique and adherence first
• Consider stepping down if … symptoms controlled for 3 months + low risk for exacerbations. Ceasing ICS is not advised.
REMEMBER TO...
GINA 2016, Box 3-5 (1/8)
© Global Initiative for Asthma

15. Picking up the concerns
Counseling and negotiating with the patient for long-term therapy on Asthma
Patient education
What is asthma?
What are the Tx options?
Patient’s preference
Inhaler techniques
Misbeliefs
How to cope with?
Picking up the concerns

16. Exhaled Breath Temperature (EBT) measurement
Monitoring
We are looking for cheaper way of measuring airway inflammation
Need validation study
Is it a substitute of Exhaled NO?

17. Management Pollicy of acute exacerbation
Trained senior nurse keep an eye on the entry point of the clinic to suspect any patient with emergency:
Warning signs:
Assess for determining the severity
Ask doctor to join the assessment
Moderate: start Tx
Severe: Try Tx
Life threatening: Immediate Hospitalization
Is it asthma?
Risk factors of asthma death?
Severity of exacerbation?
MILD or MODERATE
Talks in phrases, prefers sitting to lying, not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100–120 bpm
O2 saturation (on air) 90–95%
PEF >50% predicted or best

18. SEVERE
Talks in words, sits hunched forwards, agitated
Respiratory rate >30/min
Accessory muscles in use
Pulse rate >120 bpm
O2 saturation (on air) <90%
PEF ≤50% predicted or best

19. First-Aid Asthma: Rule of Five

20. We have well recorded data in practice software
Research in our practice:
National Asthma Prevalence Study
BOLD-BD
Detection of risk factors of Asthma
Grading COPD in other useful way
We have well recorded data in practice software
Validation of SpiroSmart

21. Take-Home message from:
Training & Continued Professional Development:
Take-Home message from:
IPCRG World Conference
Education for Health UK
NAPCON India
APSR
PULMOCON Bangladesh
Attending regional short course training on Asthma

22. Patients registered from 4th Jan to 23rd May 2016
(2142)
(198)
(326)
Male =1412
Female = 1253
47%
53%

23. We have included COPD with Asthma in Asthma group
(467)
(1180)
(327)
(150)
(18)
We have included COPD with Asthma in Asthma group

24. We also conduct Practice audit Team meeting and
Clinical meeting with colleagues
We also conduct

25. Inviting you to visit world’s largest mangrove forest
Thank you everybody
And -----
Inviting you to visit world’s largest mangrove forest
SUNDARBON