1. LIFE TIME HAPPINESS Dr.Sarma@works
Asthma is a complex disease that requires a long-term and multifaceted solution. This includes educating, treating, and providing ongoing medical care and monitoring for people with the disease, changing behaviors that lead to asthma or make it worse, and eliminating or avoiding triggers. All the topics we discuss today total “A Public Health Response to Asthma.”

2. When you can't breathe, nothing else matters®
American Lung Association

3. 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

4. COPD and Asthma Resources
ACCP
ATS
BTS
COPD profess.
GOLD
NICE
Chest Net
CDC
NAEPP
COPD Rapid series by ELSEVIER

5. CHRONIC LUNG DISEASES Pulmonary Tuberculosis Restrictive lung diseases
Suppurative lung disease
Obstructive lung diseases
Bronchial Asthma
Chronic bronchitis
Emphysema and
Their differentiations

6. AN OVERVIEW - GINA MANAGEMENT GUIDE LINES
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
, (4116)

7. WHAT IS ASTHMA ?
Primarily it is an allergic inflam-matory 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

8. BURDEN OF ILLNESS 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.

9. THE HUGE GAP 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)

10. Symptoms- (shortness of breath, cough, wheeze)
MECHANISM OF ASTHMA
Risk Factors (for development of asthma)
INFLAMMATION
Airway Hyper responsiveness
Airflow Limitation
Symptoms- (shortness of breath, cough, wheeze)
Risk Factors (for exacerbations)

11. ASTHMA : PATHOLOGY

12. 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
Occupational Sensitizers
Contributing Factors
Respiratory infections
Small size at birth
Diet
Air pollution
Outdoor pollutants
Indoor pollutants
Smoking
Passive Smoking
Active Smoking

13. 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
Dust mites thrive in soft furnishings like pillows, mattresses, carpets, and drapes. These microscopic organisms give off particles that cause allergic reactions when inhaled. They need moisture to survive and therefore thrive in humid environments. Decreasing the number of dust mites to which people with asthma are exposed may help control their asthma. One key way of doing this in the bedroom is by using mattress and pillow case covers. These bedding encasements, which are available commercially, may be plastic or vinyl and are covered with cotton, nylon, or knit fabric. They provide a barrier between the dust mites and the person with asthma. A sheet and pillow case are usually placed over the encasement for increased comfort. Any linens placed over the encasements should be washed weekly in hot water.
Down-filled pillows, quilts, or comforters should not be used. Down filling consists of tiny feathers that contain large numbers of dust mites. Also, stuffed animals and clutter should be removed from the bedroom.
If a child with asthma wants to play or sleep with a stuffed toy, wash the toy frequently in hot water, or put it in the freezer for a few hours every 2 weeks. Freezing cold kills dust mites as effectively as hot water. The hot water needs to be about 130 degrees to kill mites, and this is generally hotter than most household hot water. If you re-set your hot water heater thermostat to 130 degrees, you have to take other precautions to prevent scalding.
Another thing to consider in the bedroom is getting rid of fabric curtains and replacing them with shades or mini-blinds. Replace upholstered chairs with plastic or wood, and, if possible, get rid of carpeting in favor of vinyl or wood floors with area rugs that can be shaken out frequently. Because dust mites need high humidity, try to keep the humidity levels in your home to under 50%. In hot, humid climates, this requires the use of air conditioning and possibly dehumidifiers. In dryer, cooler climates, you may be able to achieve this by opening windows and ensuring good air flow.

14. COCKROACHES
Remove as many water and food sources as possible to avoid cockroaches.
Allergy to cockroaches is an important risk factor for worsening asthma. Decreasing exposure to cockroaches in the home can help reduce asthma attacks. To do this, remove as many water and food sources as possible because cockroaches need food and water to survive. That is why kitchens and bathrooms are areas where we commonly see cockroaches. Food, including pet food, or water anywhere in the home will attract roaches, so immediately wash soiled dishes, throw away discardable food containers, and remove standing water from all rooms. Keep trash in closed containers, and keep food covered and put away. Discard grocery bags, newspapers, cardboard boxes, and other clutter.
People tend to eat where they watch television. As a result, cockroaches and cockroach remains are frequently found in living rooms, family rooms, and bedrooms. You may find cockroaches any place where food is eaten and crumbs are left behind. These areas will need to be vacuumed or swept at least every 2-3 days to get rid of food crumbs.

15. PETS People allergic to pets should not have them in the house.
At a minimum, do not allow pets in the bedroom.
Animals are a common source of allergens. They shed fur and feathers; they leave saliva, urine, and feces. Cats and rodents are potent asthma sensitizers, whereas dogs cause less allergic sensitivity than other mammals. People with asthma may find that their pets trigger an attack. The simplest solution to this situation is, of course, to find another home for the pet. However, some pet owners may be too emotionally attached to their pets or unable to locate a safe new home for the animal. Fortunately, other steps can be taken to reduce the impact of pet allergens in the home.
At the very least, any animal causing an allergic reaction should not be allowed in the bedroom of the affected person. Pets such as cats and dogs should be kept outside as much as possible. Frequent vacuuming will help to minimize the presence of the allergen. If the room has a hard surface floor, it should be damp mopped weekly. If you have carpeting, try to use a vacuum cleaner equipped with a high-efficiency particle arresting or HEPA filter. At a minimum, use specifically designed micro-filtration vacuum cleaner bags, which can be purchased at any department store. Use pet beds or blankets that are washable, and wash them weekly. If the veterinarian says it’s OK, bathe the animal every week or two.

16. Eliminating mold may help control asthma exacerbations.
MOLDS - FUNGUS
When mold is inhaled, it can cause asthma attacks. Mold grows outdoors and indoors, especially in humid areas like bathroom showers and basements. Eliminating mold throughout the home can help control asthma attacks. To do this, one needs to keep humidity levels between 35 and 50%. A gauge called a hygrometer can be used to monitor humidity levels. When the humidity is above 60%, a dehumidifier or air conditioner should be used and the windows kept closed. If a humidifier must be used, it should be cleaned weekly with diluted bleach, and the water should be changed daily so that mold does not grow.
In the kitchen, use an exhaust fan to remove water vapor when cooking. Each week, empty water pans which are found below self-defrosting refrigerators. Remove spoiling foods immediately. Empty trash frequently to keep the home clean. In the bathroom, use an exhaust fan or open a window to remove humidity after showering. Use a squeegee to remove excess water from the shower stall, tub, and tiles.
Vent a clothes dryer by attaching a vent hose to it and running the hose outside. Dry clothes immediately after washing, either in a dryer or by hanging clothes outside.
Do not lay carpet and pad on a concrete floor. Correct seepage or flooding problems, and remove any previously flooded carpets. Ideally, people with asthma should not have bedrooms on the basement level, especially if the basement tends to be humid. Also, they should not have potted plants in their bedroom because the soil is a breeding ground for mold.
Eliminating mold may help control asthma exacerbations.

17. DIAGNOSIS OF ASTHMA History and patterns of symptoms
Physical examination
Measurements of lung function
Peak flow meter
Spirometry

18. 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)?

19. 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 ? (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

20. 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

21. PHYSICAL EXAM Hyper-expansion of the thorax
Increased nasal secretions or nasal polyps
Atopic dermatitis, eczema, or other allergic skin conditions
In the absence of specific symptoms, some physical findings still increase the possibility that a patient has asthma. These include:
A wheezing sound in the lungs
Hyperexpansion of the chest area (expansion of the area between the neck and abdomen), especially in children
Hunched shoulders
Chest deformity
Nasal swelling
Increased secretions or polyps, and
Indications of an allergic skin condition.
The physician may suggest that the patient be tested for allergies to help isolate substances to which he or she has a strong allergic reaction.

22. Peak Flow Meter is a basic tool in a GPs office
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

23. DIAGNOSTIC TEST
Diagnosis of asthma can be confirmed by demonstrating the presence of reversible airway obstruction using Spirometry.

24. SPIROMETRY
Let me now take you through to the understanding of the basics of spirometry

25. SPIROMETRY
Basic Issues

26. LUNG FUNCTION TESTS Tests of Ventilation Tests of Diffusion
Tests of Perfusion
Tests for V-P Mismatch

27. LUNG FUNCTION TESTS Tests of Ventilation Tests of Diffusion
Tests of Perfusion
Tests for V-P Mismatch

28. VENTILATION Peak Expiratory Flow Rate
Simple, Peak flow meter is used
Flow volume loop , Flow time curve
Detailed, Spirometry is used

29. PEAK FLOW METER Diagnosis of ASTHMA or COPD can be
confirmed by demonstrating the presence
of airway obstruction using Spirometry.

30. PEFR - Pros and Cons Advantages Disadvantages 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

31. SPIROMETRY

32. 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

33. 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

34. 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

35. Spirometry Normal Values
There are no fixed ‘Normal’ values
Dependent on age, sex, ht, wt, ethnicity
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

36. Obstructive v/s Restrictive
Parameter
Normal
Obstructive
Restrictive
Problem
‘Air out’ and ‘Air in’ normal
Unable to get
‘Air out’
‘Air in’
FVC
80 % of pred
Normal or ↓
↓,↓TLC
FEV1
↓-80% or less
FEV1 ÷ FVC
Min. of 75%
↓-70% or less
Normal or ↑
PEFR
FET in sec
Less than 4
Prolonged > 4
Normal - < 4

37. Flow-Volume, Volume-Time Graphs

38. Normal Flow-Volume Loop

39. Flow-Volume Loop in disease
ASTHMA
COPD
ILD
Mild reversible obstruc
Severe irreversible obstr
Severe restrictive dis

40. Office Spirometry

41. BACK TO ASTMA
Now, with this understanding of spirometry, let us proceed to look at the management of Asthma

42. CLASSIFICATION OF SEVERITY
CLASSIFY SEVERITY Clinical Features Before Treatment
Nighttime Symptoms
Symptoms
FEV1
STEP 4
Severe Persistent
Continuous
Limited physical activity
<60% predicted
Variability >30%
Frequent
STEP 3
Moderate Persistent
Daily
Use b2-agonist daily Attacks affect activity
>60%-<80% predicted
Variability >30%
>1 time week
STEP 2
Mild Persistent
>80% predicted
Variability 20-30%
>1 time a week but <1 time a day
>2 times a month
< 1 time a week
Asymptomatic and normal PEF between attacks
STEP 1
Intermittent
>80% predicted
Variability <20%
<2 times a month
The presence of one of the features of severity is sufficient to place a patient in that category.
Global Initiative for Asthma (GINA) WHO/NHLBI, 2002

43. 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

44. Preventers (long term) Peak Flow meter Spirometry Patient education
TOOL KIT WE HAVE
Relievers (Quick)
Preventers (long term)
Peak Flow meter
Spirometry
Patient education

45. 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 !

46. IT IS A DUAL PROBLEM Bronchial inflammation – perpetual
Allergic inflammation and edema
Inflammatory mediators – perpetuate
edema and excite bronchospasm
Bronchial hyper reactivity to triggers
Bronchospasm – acute attacks
This needs two different types of medicines – relievers & preventers

47. 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

48. RELIEVERS Short acting 2 agonists - SABA Salbutamol, Terbutaline
Levo-salbutamol (Levolin)
Anti-cholinergics
Ipatropium
Xanthines
Theophylline (Deriphyllin group)

49. WHAT ARE PREVENTERS ? 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

50. PREVENTERS Corticosteroids Xanthines Prednisolone, Betamethasone
Beclomethasone, Budesonide
Fluticasone
Long acting 2 agonists-LABA
Bambuterol, Salmeterol
Formoterol, Bambuderol
Anti-leukotrienes
Montelukast, Zafirlukast, Pranlukast
Xanthines
Theophylline SR
Mast cell stabilizers
Sodium cromoglycate
Nedocromil sodium
Ketotifen, Ceterizine
Combinations
Salmeterol/Fluticasone
Formoterol/Budesonide
Salbutamol/Beclomethasone

51. CERTAIN ABBREVIATIONS
ICS Inhaled corticosteroids
IBD Inhaled bronchodilators
SABA Short acting βagonists
LABA Long acting βagonists
LTA Leukotrine antagonists
OCS Oral corticosteroids
SR Sustained release
AchB Acetyl choline blockers

52. NEW APPROACHES Omalizumab injection Monoclonal antibody against
Immunoglobin E (anti-IgE)
Monoclonal antibody to block the allergic antibody, IgE

53. 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

54. LET US QUESTION ? Are we giving the right drug ?
Are we giving the drug in right form ?
Are we using the correct technique ? ?
With all intervention programs, evaluation is necessary to provide answers to two questions. First, “Are we doing the right thing?”---in other words, are we applying approaches that have been demonstrated through scientific research to improve the health of those to whom the intervention is applied? And second, “Are we doing things right?”---in other words, as we apply this proven approach, are we applying it correctly? A well-designed surveillance system coupled with appropriate process measures will provide the answers to these evaluation questions.

55. WHAT HAPPENS WITH WRONG Rx. ?
This diagram first shows you the caliber and appearance of a normal airway.
Below it, you can see an inflamed, asthmatic airway. With some treatment, the patient reaches the airway below that, but does not normalize. Most asthma patients in our country shuttle between these 2 types of airways and rarely reverse back to normal for a long time (i.e. sustained control).
The consequence of this poor control is a ‘remodeled airway after years of poor control. This airway is like an ‘inflexible’ lead pipe, a so-called fixed obstruction. Such a patient behaves similarly to a patient with COPD, and the prognosis is bad, unlike asthma diagnosed earlier and treated early.

56. THE STORY OF ASTHMA TREATMENT
This is the story of asthma treatment in India. Patients develop airway inflammation (swelling) and then start shuttling between “part” treatment and “no” treatment. This shuttling occurs in most of our patients in India.
It is only with regular inhaled steroid that this airway will return to normal. This should be our objective in asthma management.
Remodeled

57. All Asthma drugs should ideally be taken through the inhaled route.
MOST IMPORTANT
All Asthma drugs should ideally be taken through the inhaled route.

58. WHAT CHANGES THEIR LIFE ?
ICS
Inhaled corticosteroids
ICS are the most potent and effective anti-inflammatory medication currently available for Asthma *
*GINA (NHLBI & WHO Workshop Report), December 1995
*Guidelines for the diagnosis and management of Asthma NIH, NHLBI, May 1997

59. Corticosteroids ?? Inhaled medicines ??
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

60. Instead of asthma controlling our patient
REMEMBER
Instead of asthma controlling our patient
allow our patient to
control his / her asthma

61. WHY INHALATION Rx. Oral Inhaled route Slow onset of action
Large dosage used
Greater side effects
Erratic absorption
Not useful in acute illness
Inhaled route
Rapid onset of action
Less amount of drug
Drug delivered to the site of mischief
Better tolerated
Treatment of choice in acute symptoms

62. PREVENTERS Inhaled corticosteroids
Budesonide/ beclomethasone/ fluticasone – use any
Start ( mcg/day approx. in 2 divided doses)
Maintain for 3 months
Taper slowly and keep at 200 mcg
Safe for long-term use (years)
The safest and most effective preventive medication for asthma are obviously the inhaled corticosteroids.
Don’t spend hours trying to decide which one to use. Use any. So long as the inhaler is used correctly and regularly. It is recommended to start with slightly higher doses of about 800 to 1000 mcg per day , maintain that dose for at least 3 months before gradually stepping down the dose to the minimal effective dose. In very mild persistent asthma , you could also start with doses of 400 mcg per day.
Inhaled corticosteroids are never to be administered for days or weeks , but months to years.

63. 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
This slide just illustrates a lot of misconceptions about the use of inhaled corticosteroids. Tiny tots can be given these drugs safely for several years.
International athletic meets permit the use of these drugs for asthma control. These are not to be confused with Ben Johnson’s ‘steroid !’ That was an anabolic steroid which is classified as a performance-enhancing steroid and therefore banned at athletic meets.
People who feel they are addicted to these drugs should realise that there is no better addiction for an asthmatic! In fact it is sad to see so many patients using regular low doses of oral steroid ( for years on end )for asthma control, and who have never used a steroid inhaler in their life; let alone the highest possible dose of inhaled steroid, before becoming dependent on oral steroid.

64. 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
A landmark study done by Agertoft and Pedersen was published 2 years ago which has dispelled most doubts about the safety of inhaled corticosteroids in children.
332 children were recruited in this study with a mean age of 3.4 years in the steroid treated group. The mean Budesonide dose was 412 mcg per day through the study.
Although growth rates were significantly reduced during the first years of Budesonide treatment, these changes were not significantly associated with adult height. It was concluded that children who receive budesonide for long-term treatment of their asthma attain normal adult height.
It is also clear now that uncontrolled asthma is far more likely to cause growth retardation.

65. 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
Gynecologists often stop asthma treatment once pregnancy has occurred. This is another misconception that needs to be dispelled.
All anti-asthma drugs are safe during pregnancy. As far as possible inhaled medication should be used. However, if a pregnant asthmatic develops an exacerbation, then even oral or parenteral steroids may need to be promptly begun. The risks to the foetus are far higher from uncontrolled asthma during pregnancy than due to any of the anti-asthma drugs.
Asthma during pregnancy has an unpredictable course ( some patients actually feel better, some worsen and some remain the same ) and therefore patients should be strongly advised to continue their preventive medication throughout their pregnancy.
An excellent position paper in Thorax has outlined guidelines for the management of asthma during pregnancy.

66. Add Leukotriene modifier
ICS not Effective ?
Check Inhaler Technique /
Check Regular Use
Add LABA
Formoterol / Salmeterol
Add SR Theophylline
What if inhaled steroids don’t work ?
First check whether the patient is using his inhaler correctly . If he is using it correctly, then check whether he is using it regularly. Most patients who come to Chest Physicians with uncontrolled asthma are either not using any preventive medication or even if they have been prescribed it, are using the inhaler wrongly or irregularly.
Only once you are sure that the inhaled steroid is being used correctly and regularly, do you consider the usage of add-on medication.
The first choice add-on medication would be long-acting beta2-agonist , followed by a leukotriene modifier and finally sustained-release theophylline. Increasing the dose of inhaled steroid as was formerly recommended , is no longer a preferred option.
Increase dose of inhaled steroid
Add Leukotriene modifier

67. Step up and down - ACUTE SABA (IBD) in full doses
SABA Increase frequency or Nebulize
SABA as above + IPA (IBD), then add
OCS (Prednisolone) 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
No role for Theophylline; Oral SABA or LABA not very useful
We should realise now that though these are new, oral anti-inflammatory drugs for asthma, they are nowhere near the potency of inhaled corticosteroids. Being oral, these drugs have become convenient for doctors and patients alike.
Probably, one of the few indications to use these drugs first-line has been asthma in 2 to 5 years old children where one 4 mg chewable tablet needs to be given daily. In this age group it is impossible to objectively confirm a diagnosis of asthma and preventer treatment is usually based on clinical grounds. In the event of strong reluctance from parents to use inhaled steroids, a trial of montelukast may be worthwhile.
Also, all patients feeling well or partly well with ‘regular’ bronchodilators are also candidates for Montelukast, since there will be at least some anti-inflammatory activity. However, this activity if far less than that of inhaled steroids.

68. 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
We should realise now that though these are new, oral anti-inflammatory drugs for asthma, they are nowhere near the potency of inhaled corticosteroids. Being oral, these drugs have become convenient for doctors and patients alike.
Probably, one of the few indications to use these drugs first-line has been asthma in 2 to 5 years old children where one 4 mg chewable tablet needs to be given daily. In this age group it is impossible to objectively confirm a diagnosis of asthma and preventer treatment is usually based on clinical grounds. In the event of strong reluctance from parents to use inhaled steroids, a trial of montelukast may be worthwhile.
Also, all patients feeling well or partly well with ‘regular’ bronchodilators are also candidates for Montelukast, since there will be at least some anti-inflammatory activity. However, this activity if far less than that of inhaled steroids.

69. 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
We should realise now that though these are new, oral anti-inflammatory drugs for asthma, they are nowhere near the potency of inhaled corticosteroids. Being oral, these drugs have become convenient for doctors and patients alike.
Probably, one of the few indications to use these drugs first-line has been asthma in 2 to 5 years old children where one 4 mg chewable tablet needs to be given daily. In this age group it is impossible to objectively confirm a diagnosis of asthma and preventer treatment is usually based on clinical grounds. In the event of strong reluctance from parents to use inhaled steroids, a trial of montelukast may be worthwhile.
Also, all patients feeling well or partly well with ‘regular’ bronchodilators are also candidates for Montelukast, since there will be at least some anti-inflammatory activity. However, this activity if far less than that of inhaled steroids.

70. 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
If need is urgent and uncontrolled – 6 hrly
If need is maintenance, well contr. – 12 hrly
If stabilized and wants convenience – 24 hrly
We should realise now that though these are new, oral anti-inflammatory drugs for asthma, they are nowhere near the potency of inhaled corticosteroids. Being oral, these drugs have become convenient for doctors and patients alike.
Probably, one of the few indications to use these drugs first-line has been asthma in 2 to 5 years old children where one 4 mg chewable tablet needs to be given daily. In this age group it is impossible to objectively confirm a diagnosis of asthma and preventer treatment is usually based on clinical grounds. In the event of strong reluctance from parents to use inhaled steroids, a trial of montelukast may be worthwhile.
Also, all patients feeling well or partly well with ‘regular’ bronchodilators are also candidates for Montelukast, since there will be at least some anti-inflammatory activity. However, this activity if far less than that of inhaled steroids.

71. Formoterol + Budesonide combination - the Flexible Preventer
Quickly
gains control
Asthma
worsening
This illustrates beautifully the flexible nature of Formoterol- Budesonide combination in asthma practice.
Starting off with 2 Rotacaps twice daily, patients gradually get better, and after 2 months the dose can be stepped down to 1 Rotacap twice daily. During exacerbations of asthma, the dose may have to be increased again to 2 Rotacaps twice daily for a a few months and can be again reduce once control is achieved for a couple of months at least.
For patients who are controlled on 1 Rotacap twice daily for prolonged periods of time, one could even consider tapering further to a dose of just 1 Rotacap once daily. This is extremely convenient to your patients, you can imagine. Almost like taking a one-a-day tablet for hypertension control!
Reduce to
lowest adequate
dose that maintains
control
Asthma signs
Maintains
control
Maintains
control
2x2
2x2
1x1
1x2
1x2
Time

72. Why doctors don’t use inhalation therapy
Status quo : “my practice is good or ‘great’”
Oral therapy is easy
Too busy
Difficulty in convincing
Cost
Headache to explain
Many doctors feel that if they are busy in practice, they don’t need to really update themselves on newer advances in management. This is extremely true for asthma. Patients more and more, want precise information from their doctor about their disease, it’s prognosis and the best available treatment.
Doctors who tend to ignore new developments in treatment often get left behind when it comes to managing difficult patients. In fact, being very busy in practice can often be a disadvantage when it comes to the time you can spend with the patient. More and more patients are complaining that their doctors don’t give them enough time. This is dangerous because poor communication between the patient and doctor is one of the commonest reasons of consumer court cases against doctors.
Doctors cannot any longer opt for second best options for lack of time because more and more patients expect the best treatment from their doctor.
Cost of inhalation therapy is also becoming less and less of an issue when patients realise the huge amounts of money they have to pay when they get hospitalised for asthma.
Therefore, patients will soon no longer tolerate excuses from doctors on why they never received any inhalation therapy.

73. DRUG DELIVERY OPTIONS Metered dose inhalers (MDI)
Dry powder inhalers (Rotahaler)
Spacers / Holding chambers
Nebulizers

74. Demonstration of the correct technique
Ask the patient to demonstrate to you the technique

75. DRUG DELIVERY - OPTIONS
Dexterity
Hand grip strength
Co-ordination
Severity of COPD
Educational level
Age of the patient
Ability to inhale and synchronize
pMDI – Metered Dose Inhalers
Rotahalers, Diskhalers
Spacehalers
Nebulizers
Oxygen mixed delivery
Oral tablets, syrups
Parenteral – I.M or I.V use

76. WHAT DRUG DELIVERY METHOD ?
Very young or very old MDI + LV Spacer
Elderly MDI + SV spacer
Young children > 7 yrs DPI (Rotahaler)
Adults edu. understood MDI alone
Adults no co-ordination DPI (Rotahalers)
Clinic setting MDI + Spacer
Clinic - emergency Nebulizer
Choice is to be individualized
Trial and error may be needed
Cost may be a factor
We should realise now that though these are new, oral anti-inflammatory drugs for asthma, they are nowhere near the potency of inhaled corticosteroids. Being oral, these drugs have become convenient for doctors and patients alike.
Probably, one of the few indications to use these drugs first-line has been asthma in 2 to 5 years old children where one 4 mg chewable tablet needs to be given daily. In this age group it is impossible to objectively confirm a diagnosis of asthma and preventer treatment is usually based on clinical grounds. In the event of strong reluctance from parents to use inhaled steroids, a trial of montelukast may be worthwhile.
Also, all patients feeling well or partly well with ‘regular’ bronchodilators are also candidates for Montelukast, since there will be at least some anti-inflammatory activity. However, this activity if far less than that of inhaled steroids.

77. DRUG DELIVERY - OPTIONS

78. INHALATION DEVICES Rotahaler Dry powder Inhaler Metered dose
inhaler or MDI
Spacer
Spacehaler

79. MDI + LARGE VOLUME SPACER
As you can see here how easy it is to use an MDI + spacer with a baby mask for a small child.
Just apply the mask snugly over the child’s nose and mouth and then press down on the inhaler. Keep the mask tightly attached to the child’s face for at least 30 seconds for one dose.
Remember even if the child cries, the child is breathing and therefore, receives the dose adequately.

80. 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.

81. THE ZEROSTAT ADVANTAGE
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

82. DISKHALER – NEBULISER

83. NEBULISED THERAPY 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

84. 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

85. 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

86. 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.

87. 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

88. Can We dare to make them pulmonary invalids ?
LET US GIVE THEM
Can We dare to make them pulmonary invalids ?
LIFE TIME HAPPINESS