LIFE TIME HAPPINESS Dr Sarma works 1 When

LIFE TIME HAPPINESS Dr. Sarma@works 1

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

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 Dr. Sarma@works 3

COPD and Asthma Resources 1. ACCP www. chestnet. org 2. ATS www. thoracic. org 3. BTS www. brit-thoracic. org. uk 4. COPD profess. www. copdprofessional. com 5. GOLD www. goldcopd. com 6. NICE www. nice. uk. org 7. Chest Net www. chestnet. net 8. CDC www. cdc. nih. gov 9. NAEPP www. naepp. nhlbi. org Dr. Sarma@works 10. COPD Rapid series by 4

CHRONIC LUNG DISEASES l l Pulmonary Tuberculosis Restrictive lung diseases Suppurative lung disease Obstructive lung diseases – Bronchial Asthma – Chronic bronchitis – Emphysema and Their differentiations Dr. Sarma@works 5

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 602 001 + 91 9894 - 60593, (4116) 260593 Dr. Sarma@works 6

WHAT IS ASTHMA ? l l l Dr. Sarma@works Primarily it is an allergic inflam-matory disorder of the airways Infiltration of mast cells, eosinophils and lymphocytes Secondary bronchoconstriction Airway hyper-responsiveness Recurrent episodes of wheezing, coughing and shortness of breath 7

BURDEN OF ILLNESS l l l Dr. Sarma@works 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. 8

THE HUGE GAP l l l Dr. Sarma@works 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) 9

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

ASTHMA : PATHOLOGY Dr. Sarma@works 11

RISK FACTORS FOR ASTHMA Predisposing Factors l Atopy (↑ Ig. E) Causal Factors l Indoor Allergens – – Domestic mites Animal Allergens Cockroach Allergens Fungi moulds l Outdoor Allergens l Contributing Factors l l Respiratory infections Small size at birth Diet Air pollution – Outdoor pollutants – Indoor pollutants l Smoking Occupational Sensitizers – Pollens – Fungi, RSV Dr. Sarma@works – Passive Smoking – Active Smoking 12

HOUSE DUST MITE § Use bedding encasements § Wash bed linens weekly § Avoid down fillings § Limit stuffed toys to Dr. Sarma@works those 13

COCKROACHES Remove as many water and food sources as possible to avoid cockroaches. Dr. Sarma@works 14

PETS § People allergic to pets should not have them in the house. § At a minimum, do not allow pets in the bedroom. Dr. Sarma@works 15

MOLDS - FUNGUS Eliminating mold may help control asthma exacerbations. Dr. Sarma@works 16

DIAGNOSIS OF ASTHMA History and patterns of symptoms l Physical examination l Measurements of lung function l – Peak flow meter – Spirometry Dr. Sarma@works 17

PATIENT HISTORY Has the patient had an attack or recurrent episodes of wheezing? l Does the patient have a troublesome cough, worse particularly at night, or on awakening? l Does the patient cough after physical activity (eg. Playing)? l Does the patient have breathing problems during a particular season Dr. Sarma@works(or change of season)? l 18

MAIN SYMPTOM CLUES l l l Dr. Sarma@works 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. 19

PHYSICAL EXAM l l l 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 Dr. Sarma@works 20

PHYSICAL EXAM l l l Dr. Sarma@works Hyper-expansion of the thorax Increased nasal secretions or nasal polyps Atopic dermatitis, eczema, or other allergic skin conditions 21

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 Dr. Sarma@works 22

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

SPIROMETRY Let me now take you through to the understanding of the basics of spirometry Dr. Sarma@works 24

SPIROMETRY Basic Issues Dr. Sarma@works 25

LUNG FUNCTION TESTS l Tests of Ventilation l Tests of Diffusion l Tests of Perfusion l Tests for V-P Mismatch Dr. Sarma@works 26

LUNG FUNCTION TESTS l Tests of Ventilation l Tests of Diffusion l Tests of Perfusion l Tests for V-P Mismatch Dr. Sarma@works 27

VENTILATION l Peak Expiratory Flow Rate – Simple, Peak flow meter is used l Flow volume loop , Flow time curve – Detailed, Spirometry is used Dr. Sarma@works 28

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

PEFR - Pros and Cons l Advantages – With in 1 to 2 minutes, – Inexpensive (meter costs less than Rs. 1000) – Simple, useful for frequent follow up use l Disadvantages – Very much effort dependent – Insensitive to small changes – Small airways cannot be assessed – Large inter & intra subject variation; ↓accurate Dr. Sarma@works 30

SPIROMETRY Dr. Sarma@works 31

Spirometry - Pros and Cons l 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 l Disadvantages – Cost about 50, 000 + computer and printer – Takes time to perform – 10 to 15 minutes – Requires training – at least one day course Dr. Sarma@works 32

Spirometry Maneuver In single breath test l A few normal tidal respirations l Then deeeeep inspiration l Momentary breath holding l Very forced and fast expiration – As hard and as fast as he/she can blow out l Then deep, quick and full inspiration l Repeat at least 3 times – take the best Dr. Sarma@works 33

Spirometry Results l FVC Forced Vital Capacity l FEV 1 Forced Expiratory Volume in the first second l FEV 1÷FVC Ratio of the above two l PEFR Peak Expiratory Flow Rate l FET Forced Expiratory Time Dr. Sarma@works 34

Spirometry Normal Values There are no fixed ‘Normal’ values 2. Dependent on age, sex, ht, wt, ethnicity 3. Observed value expressed as predicted value % 1. l l l FVC FEV 1/FVC PEFR FET Dr. Sarma@works Normal if > 80% of predicted At least 75% Normal if > 80% of predicted Less than 4 seconds 35

Obstructive v/s Restrictive Parameter Normal Problem FVC FEV 1 ÷ FVC PEFR Dr. Sarma@works Obstructive Restrictive ‘Air out’ and Unable to ‘Air in’ get normal ‘Air out’ 80 % of pred Normal or ↓ Unable to get ‘Air in’ ↓, ↓TLC 80 % of pred ↓-80% or less Min. of 75% ↓-70% or less 80 % of pred ↓-80% or less Normal or ↑ Normal 36

Flow-Volume, Volume-Time Graphs Dr. Sarma@works 37

Normal Flow-Volume Loop Dr. Sarma@works 38

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

Office Spirometry Dr. Sarma@works 40

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

CLASSIFICATION OF SEVERITY CLASSIFY SEVERITY STEP 4 Severe Persistent STEP 3 Moderate Persistent STEP 2 Mild Persistent STEP 1 Intermittent Clinical Features Before Treatment Nighttime FEV 1 Symptoms Continuous <60% predicted Frequent Limited physical Variability >30% activity Daily Use b 2 -agonist daily Attacks affect activity >1 time a week but <1 time a day < 1 time a week Asymptomatic and normal PEF between attacks >1 time week >2 times a month <2 times a month >60%-<80% predicted Variability >30% >80% predicted Variability 2030% >80% predicted Variability <20% The presence of one of the features of severity is sufficient to place Dr. Sarma@works patient in that category. a Global Initiative for Asthma (GINA) WHO/NHLBI, 2002 42

GOALS IN ASTHMA CONTROL l Achieve and maintain control of symptoms l Prevent asthma episodes or attacks l Minimal use of reliever medication l No emergency visits to doctors or hospitals l Maintain normal activity levels, including exercise l Maintain pulmonary function as close to normal as possible l Minimal (or no) side effects from medicine Dr. Sarma@works 43

TOOL KIT WE HAVE l l l Dr. Sarma@works Relievers (Quick) Preventers (long term) Peak Flow meter Spirometry Patient education 44

ASTHMA Rx. in INDIA TOADAY l Completely control symptoms and l Make their life normal l As good as abroad (even better) l General practice physicians l Doesn’t need Chest Physicians ! Dr. Sarma@works 45

IT IS A DUAL PROBLEM 1. Bronchial inflammation – perpetual 1. 2. 3. 4. Allergic inflammation and edema Inflammatory mediators – perpetuate edema and excite bronchospasm Bronchial hyper reactivity to triggers 2. Bronchospasm – acute attacks l This needs two different types of medicines – relievers & preventers Dr. Sarma@works 46

WHAT ARE RELIEVERS ? l l l l Dr. Sarma@works 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 47

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

WHAT ARE PREVENTERS ? l l l Dr. Sarma@works l Prevent future attacks Reduce allergic inflammation Reduce inflammatory mediators Reduce hyperresponsiveness Long term control of asthma Prevent airway remodeling 49

PREVENTERS Corticosteroids Prednisolone, Betamethasone Beclomethasone, Budesonide Fluticasone Long acting 2 agonists. LABA Bambuterol, Salmeterol Formoterol, Bambuderol Dr. Sarma@works Xanthines Theophylline SR Mast cell stabilizers Sodium cromoglycate Nedocromil sodium Ketotifen, Ceterizine Combinations Salmeterol/Fluticasone Formoterol/Budesonide Salbutamol/Beclometha sone 50

CERTAIN ABBREVIATIONS l ICS IBD SABA Inhaled corticosteroids Inhaled bronchodilators Short acting βagonists l LABA Long acting βagonists l LTA Leukotrine antagonists l OCS SR Ach. B Oral corticosteroids Sustained release Acetyl choline blockers l l Dr. Sarma@works 51

NEW APPROACHES l l Dr. Sarma@works Omalizumab injection Monoclonal antibody against Immunoglobin E (anti-Ig. E) Monoclonal antibody to block the allergic antibody, Ig. E 52

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 Dr. Sarma@works 53

LET US QUESTION § Are we giving the right drug ? § Are we giving the drug in right form ? § Are we using the correct technique ? Dr. Sarma@works 54

WHAT HAPPENS WITH WRONG Rx. ? Dr. Sarma@works 55

THE STORY OF ASTHMA TREATMENT Remodeled Dr. Sarma@works 56

MOST IMPORTANT All Asthma drugs should ideally be taken through the inhaled route. Dr. Sarma@works 57

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

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 Dr. Sarma@works 59

REMEMBER Instead of asthma controlling our patient allow our patient to control his / her asthma Dr. Sarma@works 60

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

PREVENTERS Inhaled corticosteroids l Budesonide/ beclomethasone/ fluticasone – use any l Start (400 -1000 mcg/day approx. in 2 divided doses) l Maintain for 3 months l Taper slowly and keep at 200 mcg l Safe for long-term use (years) Dr. Sarma@works 62

ICS – HOW SAFE ? They are very safe l Even in small children for several years l 30% of Olympic athletes use ICS l Not anabolic (performance-enhancing) steroid l Even highest ICS dose is safer than low dose oral steroid or beta agonist l Best “Addiction” for asthmatics Dr. Sarma@works 63

ICS SAFE EVEN FOR A CHILD? 400 mcg/day (budesonide) l Over 9 years of continuous use l No growth retardation l Uncontrolled asthma causes growth retardation l Pedersen & Agertoft NEJM 2000 Dr. Sarma@works 64

PREGNANCY AND ASTHMA Don’t x-ray (if possible) l All asthma medication is safe l Even oral corticosteroids are safe for exacerbations l Uncontrolled asthma during pregnancy is a serious risk factor foetal distress and anoxia l Thorax Supplement Dr. Sarma@works 65

ICS not Effective ? Check Inhaler Technique / Check Regular Use Increase dose of inhaled steroid Dr. Sarma@works Add LABA Formoterol / Salmeterol Add SR Theophylline Add Leukotriene modifier 66

Step up and down - ACUTE SABA (IBD) in full doses l SABA Increase frequency or Nebulize l SABA as above + IPA (IBD), then add l OCS (Prednisolone) 30 -60 mg for 3 to 10 days add l ICS (1000 mcg) / day and maintain for 6 weeks minimum l Gradually bring down doses and maintain with ICS l If symptoms are not relieved – l Check the technique and the compliance with Rx. l Look for aggravating factors like – Dr. Sarma@works GE Reflux, Emotions/ stress, Sinusitis 67 – Allergic Rhinitis, Persistent allergens l

The Step Care Approach - Prevent ICS l ICS + LABA (IBD) + Double Dose ICS l ICS (DD) + LABA + LTA (oral) l ICS (DD) + LABA + LTA + OCS + TIO (IBD) l SR Theophylline may be add on l SABA or LABA Oral + IPA (IBD) may be useful add on l No long acting steroid injections Dr. Sarma@works l No injectable or short acting Theophylline l 68

Leukotriene Modifiers l Oral leukotrine antagonist – anti inflammatory l Not as effective as inhaled steroid l May be first-line for 2 to 5 yr. olds. l Montelukast available; Zafirlukast is not in India l 4 mg, 5 mg, 8 mg tabs available l Can be add on to ICS, IBD inhalers Dr. Sarma@works 69

NOT ALL ARE SAME !! Beclomethasone 6 hrly + Salbutamol 6 th hrly l Budesonide 12 hrly + Salmeterol 12 hrly l Salmeterol 12 hrly + Ipatropium 12 hrly l Fluticasone 24 hrly + Formoterol 24 hrly l Formoterol 24 hrly + Tiotropium 24 hrly Choice is based on 1. If need is urgent and uncontrolled – Dr. Sarma@works 6 hrly l 70

Formoterol + Budesonide combination - the Flexible Preventer Asthma worsening Asthma signs Quickly gains control 2 x 2 Dr. Sarma@works Maintains control 1 x 2 2 x 2 Time 1 x 2 Reduce to lowest adequate dose that maintains control 1 x 1 71

Why doctors don’t use inhalation therapy l Status quo : “my practice is good or ‘great’” l Oral therapy is easy l Too busy l Difficulty in convincing l Cost l Headache Dr. Sarma@works to explain 72

DRUG DELIVERY OPTIONS Metered dose inhalers (MDI) l Dry powder inhalers (Rotahaler) l Spacers / Holding chambers l Nebulizers l Dr. Sarma@works 73

Demonstration of the correct technique Dr. Sarma@works Ask the patient to demonstrate to you the technique 74

DRUG DELIVERY - OPTIONS 1. Dexterity l 2. Hand grip strength p. MDI – Metered Dose Inhalers l Rotahalers, Diskhalers 3. Co-ordination l Spacehalers 4. Severity of COPD l Nebulizers 5. Educational level l Oxygen mixed delivery 6. Age of the patient l Oral tablets, syrups 7. Ability to inhale and synchronize l Parenteral – I. M or I. V use Dr. Sarma@works 75

WHAT DRUG DELIVERY METHOD ? Very young or very old Spacer l Elderly spacer l Young children > 7 yrs (Rotahaler) l Adults edu. understood l Adults no co-ordination (Rotahalers) l Clinic setting Dr. Sarma@works Spacer l MDI + LV MDI + SV DPI MDI alone DPI MDI + 76

DRUG DELIVERY - OPTIONS Dr. Sarma@works 77

INHALATION DEVICES Rotahaler Dry powder Inhaler Dr. Sarma@works Metered dose inhaler or MDI Spacer Spacehaler 78

MDI + LARGE VOLUME SPACER Dr. Sarma@works 79

ROTAHALER – DRY POWDER Overcomes hand-lung coordination problems encountered with MDIs. l Can be easily used by children, elderly and arthritic patients. l Can take multiple inhalations if the entire drug has not been inhaled in one inhalation. l Dr. Sarma@works 80

THE ZEROSTAT ADVANTAGE 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 Dr. Sarma@works drug 1. 81

DISKHALER – NEBULISER Dr. Sarma@works 82

NEBULISED THERAPY 1. 2. 3. 4. 5. Dr. Sarma@works 6. 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 Na. Cl (not DW) If decided to use ICS (FEV 1 < 50%) – 83

PATIENT EDUCATION l Explain nature of the disease (inflammation) l Explain action of prescribed drugs l Stress the need for regular, long-term therapy l That way only we can convince l Allay fears and concerns l Peak flow testing Dr. Sarma@works 84

PATIENT EDUCATION l Asthma is a common disorder l It can happen to anybody, May not be life long l It is not caused by supernatural forces l Asthma is not contagious, All kin needn’t be affected l Recurrent attacks of cough with or without wheeze Between attacks people with asthma lead Dr. Sarma@works normal lives as anyone else l 85

PATIENT EDUCATION l Asthma can be effectively controlled, although it cannot be cured. l 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 Dr. Sarma@works least possible medication. l 86

YOURS FAITHFULLY REQUESTS l A little time spent talking to our patients - really is a great investment. l This may make all the difference between a happy life and pulmonary invalidity Dr. Sarma@works 87

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