7 Asthma & COAD What a Primary Physician need to know.pptx

7 Asthma & COAD What a Primary Physician need to know

1. Asthma & COAD: What a Primary Physician need to know Dr. Kamal Kishore MD Consultant Physician Geetanjali Hospital Hisar Geetanjali Hospital Hisar

2. Main Respiratory Diseases Allergic Rhinitis Asthma COPD

3. No. of patients with Asthma Asthma often begins in childhood. Estimated prevalence of Asthma is increasing 50% every 10 years 30 CRORES 1.5 – 2 CRORES

4. Parts of the respiratory system

5. AIRWAYS Parts of the respiratory system (Contd…)

6. Asthma is a long term disease that affects the airways. Tubes that carry air in and out of your lungs.

7. In Asthma… Inner walls of the airways are inflamed ( swollen ). Airways become very sensitive Airways react strongly to things that the patient is allergic to or finds irritating.

8. Definition Asthma is a Chronic Inflammatory Disease characterized by Airway Hyperresponsiveness to a variety of stimuli resulting in Bronchospasm which reverses, spontaneously or with treatment.

9. Triggers Dust mite Triggers are things that when inhaled can start asthma. They can vary from person to person. Dust Smoke Cigarette smoke Smoke from firecrackers Pollen from plants Animal dander Exercise Cold air Strong smells Recognition of asthma triggers and avoiding them is the first step towards controlling asthma…

10. On entry of these triggers The airways get narrower Less air flows through the lungs AIRWAY OBSTRUCTION (Blockage in the airways) This causes symptoms of asthma

11. Asthma Symptoms Breathlessness or dyspnea (especially at night or after some exertion) Wheezing (a whistling sound while breathing out) Cough (especially at night or after some exertion) Chest tightness (feeling of congestion)

12. Asthma Attack An asthma attack is when your asthma symptoms become much worse all of a sudden

13. Diagnosing Asthma History taking Measurements of lung function Bronchodilator reversibility test

14. 1. History taking Does the patient have a troublesome cough , worse particularly at night, or on awakening? Does the patient cough after physical activity (e.g...... Playing)? Does the patient have breathing problems during a particular season (or change of season)? 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? Do you get relief ?

15. If the patient answers “ YES ” to any of the above questions , suspect Asthma. Also a doctor should ask about: Does anyone else in the family suffer from asthma, allergies, frequent colds ?

16. 2. Measurements of lung function The Breath-o-Meter The thermometer for Asthma

17. Breathometer Monitor PEFR Geetanjali Hospital Hisar

18. If spirometry is not available Use this simple device Geetanjali Hospital Hisar

19. Measure peak flow reading 2. Give bronchodilator 4. Measure peak flow reading again 3. Wait for 10 to 15 minutes 5. If: 15 – 20 % increase in this reading from previous 6. Indication of a significant degree of reversible airflow obstruction ASTHMA 3. Bronchodilator reversibility test

20. All that wheezes is not Asthma Anaphylaxis Partial endobronchial obstruction COPD Cardiac Asthma Pneumonia Acute Allergic Bronchitis etc.

21. Treatment of Asthma

22. Non-Pharmacological Measures Environmental Control Avoidance of Triggers

23. Routes of administration of anti-asthma drugs Oral Inhaled Parenteral Tablets Syrup Metered dose inhaler (MDI) Dry powder inhaler (DPI) Injections Nebulizers

24. Eyes Skin Nasal blockage Lungs Eye Drops Ear Drops Lotions / ointments Nasal inhaler INHALERS NOT ORALS Ears ORAL OR INHALED ?

25. For Example….. Tab ASTHALIN 4mg = 4000 mcg 100mcg/Puff ASTHALIN x 2 puff = 200 mcg 20 times less drug is required for desired effect from INHALATION route! 4000/200 = 20 ORAL OR INHALED ?

26. Oral Large dosage used Greater side effects Slow onset of action Not useful in acute symptoms Inhaled Small amount of dosage used Lesser side effects Fast onset of action (e.g..... bronchodilators) Useful in acute symptoms ORAL OR INHALED ?

27. Advantages of inhalation therapy over oral route Direct action in lungs Quick onset of Action Small doses required Minimum side effects

28. Asthma Disease Management Bronchospasm & inflammation ( swelling ) Bronchospasm needs a Reliever Bronchodilator Inflammation ( Swelling) needs a Controller Anti-inflammatory

29. Why should Controller Drugs be used Regularly?

30. Drug treatment Bronchodilators Anti-inflammatory Relievers Controllers Duration of action: short Duration of action: long Onset of action: faster Onset of action: slower Quickly relieve symptoms Prevent asthma attacks Rescue medicine Regular medicine

31. Classes of drugs for asthma RELIEVERS Short acting bronchodilators CONTROLLERS Long acting bronchodilators Inhaled Corticosteroids Combination Therapy Anti Leukotrienes

32. AVAILABLE RELIEVERS Short acting bronchodilators Salbutamol Levosalbutamol To be taken as and when required

33. AVAILABLE CONTROLLERS Inhaled corticosteroids Beclomethasone Budesonide Fluticasone Ciclesonide Long acting bronchodilators Salmeterol Formoterol Anti- leukotrienes Montelukast To be taken regularly , whether patient has symptoms or not

34. ICS + bronchodilators Beclomethasone + Salbutamol Beclomethasone + Formoterol Salmeterol + Fluticasone Budesonide + Formoterol Ciclesonide + Formoterol Beclomethasone + Formoterol To be taken regularly , whether patient has symptoms or not AVAILABLE CONTROLLERS (Contd…)

35. Stepwise approach to control asthma symptoms and reduce risk GINA 2014, Box 3-5 NEW!

36. Stepwise management - pharmacotherapy *For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS **For patients prescribed BDP/formoterol or BUD/ formoterol maintenance and reliever therapy GINA 2014, Box 3-5 (upper part)

37. Step 1 – as-needed inhaled short-acting beta 2 -agonist (SABA) *For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS **For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy GINA 2014, Box 3-5, Step 1

38. Step 2 – low-dose controller + as-needed inhaled SABA *For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS **For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy GINA 2014, Box 3-5, Step 2

39. Step 3 – one or two controllers + as-needed inhaled reliever *For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS **For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy GINA 2014, Box 3-5, Step 3

40. Step 4 – two or more controllers + as-needed inhaled reliever *For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS **For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy GINA 2014, Box 3-5, Step 4

41. Step 5 – higher level care and/or add-on treatment *For children 6-11 years, theophylline is not recommended, and preferred Step 3 is medium dose ICS **For patients prescribed BDP/formoterol or BUD/formoterol maintenance and reliever therapy GINA 2014, Box 3-5, Step 5

42. COPD Chronic Obstructive Pulmonary Disease Disease - Illness Obstructive - Partly blocked Chronic - Will not go away Pulmonary - Related to lungs

43. How COPD has affected my life… I have to gasp for breath even when I walk a short distance… I was a football & hockey player in early life; but now I cant even play with my grandchildren… When I do my normal routine work; I feel breathless & stressed up…. I am NOT able to enjoy normal life &I wish I could breathe out more freely, without gasping…..

44. 60 % to 65 % reduction in death rates due to coronary heart disease and stroke 150 % increase in death rates due to COPD ! Geetanjali Hospital Hisar

45. World’s top ten killers

46. World’s top ten killers

47. COPD The disease of the future… Geetanjali Hospital Hisar

48. IN INDIA…

49. Definition…. Chronic Obstructive Pulmonary Disease ( COPD ), is characterized by the limitation of airflow in the airway that is NOT fully reversible . COPD is the umbrella term for chronic bronchitis and emphysema .

50. What Is Chronic Bronchitis & Emphysema ? Chronic bronchitis is irritability of the breathing tubes (bronchi or bronchioles) and results in increased mucus production and a constant swelling . Emphysema is a disease that involves the alveoli (air sacs) of the lung. In emphysema, the walls of some of the alveoli have been destroyed .

51. COPD is most often due to Bidi and Cigarette smoking , but can be due to other reasons also. Causes of COPD

52. Causes of COPD Smoking Pollution Chullah smoke Occupational exposure

53. Symptoms of COPD Continuous productive cough (some type of secretions come up during coughing ) Exertional dyspnoea (breathlessness during any physical activity) Progressive breathlessness (breathlessness increasing day by day)

54. COPD is An Iceberg disease Geetanjali Hospital Hisar

55. Caused by Cigarettes, noxious particles or gases Preventable & Treatable Airflow limitation progressive & Not fully reversible Abnormal Inflammatory response COPD Extra pulmonary Effects Geetanjali Hospital Hisar

56. Disease Trajectory of a Patients with COPD Symptoms Exacerbations Exacerbations Exacerbations Deterioration End of Life Geetanjali Hospital Hisar

57. Think of COPD when….. Adult (>45) onset of symptoms Absence of family history of atopy Not so dramatic response to steroid ‘bursts’ Beedi or cigarette smoker Not so pronounced wheeze, prolonged expiration and diminished breath sounds Geetanjali Hospital Hisar

58. To the COPD patient, this is a breathtaking view Geetanjali Hospital Hisar

59. Breathlessness the most common and bothersome symptom in COPD Develops insidiously and may be regarded as a normal part of ageing Patients often modify activities/behavior that provoke breathlessness Subjective breathlessness correlates poorly with degree of airflow obstruction It can be quantified by using different scales Geetanjali Hospital Hisar

60. So why diagnose COPD at all ? 1) Because you can make your patient cope more , do more and walk more without symptoms 2) Because the prognosis isn ’ t as good as asthma and the patient needs to hear it from his physician first Geetanjali Hospital Hisar

61. SYMPTOMS Cough Sputum Dyspnea Exposure to risk factors Tobacco smoke Occupation Indoor/outdoor pollution SPIROMETRY How to diagnose COPD SUSPECT CONFIRM

62. SPIROMETRY The spirometry test is performed using a device called a spirometer .

63. Why get a Spirometry done? To answer the following questions: Is it COPD ? How bad is the COPD? (like a stress test for IHD) Is it definitely not asthma? Will steroids benefit? Geetanjali Hospital Hisar

64. Classification of Severity of Airflow Limitation in COPD (Based on Post=Bronchodilator FEV 1 In patients with FEV 1/ FVC <0.70: Gold 1: Mild FEV 1 > 80% predicted Gold 2: Moderate 50% < FEV 1 <80% predicted Gold 3: Severe 30% < FEV 1 <50% predicted Gold 4: Very Severe FEV 1 <30% predicted

65. Goals of COPD treatment Reduce symptoms (like breathlessness and cough) Improve exercise tolerance (ability to perform exercise) Improve overall health status Prevent and treat exacerbations (attacks) Prevent mortality (Death)

66. Management of COPD Stable Phase of COPD Acute Exacerbation of COPD

67. Why should you treat COPD even when it is stable ? Geetanjali Hospital Hisar

68. Stable Phase of COPD Anti-Smoking Measures Bronchodilator Therapy Corticosteroids Oxygen Non-Invasive Ventilation Treatment of Airway Secretions Nutrition Pulmonary Rehabilitation Lung Volume Reduction Surgery

69. Drug Management for COPD Short-acting Bronchodilators Long-acting Bronchodilators Others Steroids ICS + Long –acting bronchodilators Mucolytics PDE4  inhibitor

70. Drugs for COPD SHORT-ACTING BRONCHODILATORS Salbutamol Levosalbutamol Ipratropium + Levosalbutamol Ipratropium

71. LONG-ACTING BRONCHODILATORS Salmeterol SEROBID Formoterol FORATEC Tiotropium TIOVA Doxofylline ZORDOX Drugs for COPD Tiotropium + formoterol DUOVA

72. Treatment strategies: Drugs Bronchodilators Short acting Long acting Combinations of both short and long acting Anti-inflammatory ICS Combinations of ICS and LABA Combinations of LAMA, LABA and ICS Anti-oxidants/mucolytics: N-acetyl cysteine Geetanjali Hospital Hisar

73. Long-acting Beta2-agonists (LABA) Formoterol Arformoterol Indacaterol Salmeterol Geetanjali Hospital Hisar

74. Long-acting Anticholinergics (LAMA) Aclidinium bromide Glycopyrronium bromide Tiotropium Geetanjali Hospital Hisar

75. Inhaled corticosteroids (ICS) Beclomethasone Budesonide Fluticasone Ciclosonide Mometasone Geetanjali Hospital Hisar

76. Combination long-acting beta -agonists + corticosteroids in one inhaler (LABA+ICS) Formoterol/ Budesonide (Foracort) Formoterol/ mometasone (Evocort) Formoterol/ Beclomethasone (Full form) Formoterol/ Fluticasone (Maxiflo) Salmeterol/ Fluticasone (Seroflo) Geetanjali Hospital Hisar

77. Combination long-acting beta2 –agonists + anticholinergics in one inhaler (LABA+LAMA) Formoterol/ Tiotropium (Duova) Geetanjali Hospital Hisar

78. Combination long-acting beta –agonists + anticholinergics + corticosteroids in one inhaler (LABA+LAMA+ICS) Formoterol/ Tiotropium/ Ciclesonide ( Triohale) Geetanjali Hospital Hisar

79. Inhalation devices Geetanjali Hospital Hisar

80. Best treatment of COPD is to stop smoking Geetanjali Hospital Hisar

81. Brief Strategies to help the patient willing to Quit ASK: Systematically identify all tobacco users at every visit. Implement an office-wide system that insure that, for EVERY patient at EVERY clinic visit, tobacco-use status is queried and documented. ADVISE: Strongly urge all tobacco users quit. In a clear, strong and personalized manner, urge every tobacco user to quit. ASSESS: Determine willingness to make a quit attempt. Ask every tobacco user if he or she is willing to make a quit attempt at this time (e.g. within the next 30days) ASSIST: Aid the patient in quitting. Help the patient with a quit plan; provide practical counseling; provide intra-treatment social support; help the patient obtain extra-treatment social support; recommend use of approved pharmacotherapy except in special circumstances; provide supplementary materials. ARRANGE: Schedule follow-up contact. Schedule follow-up confact, either in person or via telephone.

82. Bronchodilators in Stable COPD Bronchodilator medications are central to symptom management in COPD Inhaled therapy is preferred The choice between beta2-agonist, anticholinergic, theophyline, or combination therapy depends on availability and individual patient response in terms of symptoms relief and side effects. Bronchodilator are prescribed on an-needed or on a regular basis to prevent or reduce symptoms. Long-acting inhaled bronchodilators are convenient and more effective at producing maintained symptom relief than short-acting Bronchodilators. Combining Bronchodilators of different pharmacological classes may improve efficacy and decrease the risk of side effects compared to increasing the dose of a single Bronchodilator. Geetanjali Hospital Hisar

83. Geetanjali Hospital Hisar

84. Acute Exacerbation of COPD (AECB) Oxygen Bronchodilator Therapy Corticosteroids Treatment of Respiratory Infection Physiotherapy Non-Invasive Ventilation Mechanical Ventilation

85. Impact of exacerbations Hospitalizations Additional medications like steroids, antibiotics, oxygen etc Increased health care resource utilization Worsened QoL Increase rate of disease progression Risk of mortality Geetanjali Hospital Hisar

86. Indications for ICU Admission Severe dyspnea that responds inadequately to initial emergency therapy. Changes in mental status (confusion, lethargy, coma) Persistent or worsening hypoxemia (PaO2<5.3 kPa 40mmHg) and/or severe/worsening respiratory scidosis (pH< 7.25 ) despite supplemental oxygen and noninvasive ventilation. Need for invasive mechanical ventilation. Hemodynamic instability – need for vasopressors.

87. Mechanical Ventilation Refractory Hypoxemia Rising PaCO2 Decreased Mental Status Hemodynamic Instability Respiratory Exhaustion

88. Use nebulizer in emergency conditions Geetanjali Hospital Hisar

89. Oxygen Therapy The long-term administration of oxygen (>15 hours per day) to patients with chronic respiratory failture has been shown to increase survival in patients with severe resting hypoxemia (Evidence B). Long-term oxygen therapy is indicated for patients who have: PaO 2 at or below 7.3 kPa (55 mmHg) or SaO 2 at or below 88%, with or without hypercapnia confirmed twice over a three week period (Evidence B): or PaO 2 between 7.3 kPA (55 mmHg) and 8.0 kPa (60 mmHg), or SaO2 of 88%, if there is evidence of pulmonary hypertension, peripheral edema suggesting congestive cardiac failure, or polycythemia (hematocrit > 55%) (Evidence D).

90. Oxygen delivery devices Geetanjali Hospital Hisar

91. Discharge Criteria Able to use long acting bronchodilator, either beta 2 –agonists and/or anticholinergics with or without inhaled corticosteroids. Inhaled short-acting beta 2 –agonist therapy is required no more frequently than every 4hours. Patient if previously ambulatory, is able to walk across room Patient is able to eat and sleep without frequent awakening by dyspnea. Patient has been clinically stable for 12-24 hrs. Arterial blood gases have been stable for 12-24 hrs. Patient (or home caregiver) fully understands correct use of medications. Follow-up and home care arrangements have been completed (e.g. visiting nurse, oxygen delivery, meal provisions) Patients, family and physician are confident that the patient can manage successfully at home.

92. Other Pharmacologic Treatments Vaccines Influenza vaccination can reduce serious illness (such as lower respiratory tract infections requiring hospitalization) and death in COPD patients (Evidence A). Vaccines containing killed or live, inactivated viruses are recommended as they are more effective in elderly patients with COPD. The strains are adjusted each year for appropriate effectiveness and should be given once each year. Pneumococcal polysaccharide vaccine is recommended for COPD patients 65 years and older, and also in younger patients with significant comorbid conditions such as cardiac disease.

93. Differences between COPD & Asthma

94. Asthma is not COPD ! Mid-life Progressive Exertional Long smoking hist ory Not fully Reversible Early in life vary from day to day  night/early morning Atopy Family history of asthma Reversible Onset Symptoms Risk factors Airway obstruction Geetanjali Hospital Hisar

95. Breathe Fresh

96. Geetanjali Hospital Hisar