Difficult Asthma by Dr. S.K Jindal | Jindal Chest Clinic

Difficult Asthma: Its types, Risk factors, treatment, Management, etc. For more information, please contact us: 9779030507.

1. DIFFICULT ASTHMA
Dr. S. K. Jindal
www.jindalchest.com

2. Difficult Asthma
“Difficult”forthepatient
“Difficult”forthephysician
“Difficult”forthefamily
“Difficult”forthesociety

3. Clinical Spectrum of Asthma
Mild
Intermittent
Severe
Persistent

4. Confusing Terminology
•“Severe” asthma
•“Difficult” asthma
•“Difficult to control” asthma
•“Steroid dependent &/or resistant” asthma
•“Irreversible” asthma
•“Brittle” asthma
•“Refractory” asthma (ATS)

5. Difficult Asthma
•Asthmawhichisdifficulttocontrolwithmaximum
treatmentrecommendedasappropriateforthatstage…
•Persistenceofsymptoms,frequentexacerbationsorairway
obstructiondespitehigh(oroptimum)medication

6. Case Report (Brittle Asthma)
42 F, Asthmatic
Daily drug intake (SVC catheter)
•Theophylline 200 mg X 5 times
•Prednisolone 50 mg bd
•Terbutaline 0.25 mg tds(S/C)
•Inhalations: Terbutaline2 puffs X 6
Ipratropium2 puffs X 6
Budesonide1200 ug
•Frequent hospitalization
•Added: continuous IV infusion of theophyllinewith CADD I-pump
Speelberget al, ERJ, 1988

7. K60F,Housewife
•Asthma>30yrs
•Obesity,diabetes,hypertension,IHD,GER,cholelithiasis,OA,UV
prolapse,panic-anxietysyndrome
Asthmatmt:Fluticasone 100mg
Salmetrol100mg
Ipratropium 2puffQDS
Theophylline 300mgBD
Montelukast 10mgOD
Frequentoral/parenteralCS,antibiotics,mucolytics(etc.)

8. AS48M,Teacher:NFA
•Knownasthma>15yrs
•Oraldiclofenacforpain
Severeattackafter3hours
•Duringtransportation:fell,gasping,hypotension
•Intubated;Ambubagvent.
•Mechvent(CMV12)V
T400ml,FiO
21–0.6
Weaning(Tpiece)after4hrs.

9. What is Difficult Asthma?
A.Difficulttodiagnose–
•Thebasicdisease(wrongdiagnosis)
B.Difficulttomanage:
1.Thediseaseassociations
2.Thetriggercontrol
3.Acuteexacerbation
Fatalityproneasthma
Statusasthmatics
Steroidresistant

10. Difficult Asthma
Epidemiology
•Rare,<5%
•Althoughrare,butaccountformajorityoftheasthmainducedburden
through:
•Frequenthospitalization
•ERvisits
•Absencefromworkorschool
•Useofmedications
•Higherprevalenceamongyoungfemales(15-30years)
[AJRCCM 2000; 162: 2341]

11. Brittle Asthma
•Turner-Warwick (1977) : “Chaotic” patterns on the daily PEF
monitoring
•BTS asthma guidelines: “Sudden life threatening” attacks
usually without pre-morbidity

12. Definitions
“TypeI”BrittleAsthma
40%diurnalvariationinPEF
Maintainedover>50%ofatimeperiodofatleast150days
Despitemaximalmedicaltreatmentincludinginhaledcortico-steroids(iCS)of
1500mgBDPorequivalent.
“TypeII”BrittleAsthma
Suddenacuteattacksoccurringin<3hrsonabackgroundofapparentlywell
controlledasthma
[Thorax 1998; 53: 315-321]

13. Refractory Asthma (ATS)
MajorCharacteristics
Controlrequiringuseof:
1.continuousornearcontinuous(>50%ofyear)oralsteroids
2.highdoseiCS(>1260BDP,etc)
MinorCharacteristics
1.UseofdailycontrollermedicationsinadditiontoiCS
2.Shortactingβ-agonistuseonadailybasis
3.Persistentairwayobstruction
4.OneormoreERvisitsperyear
5.Threeormoreoralsteroid‘bursts’peryear
6.Promptdeteriorationonreducingoralsteroids
7.Nearfatalasthmaeventinpast
[AJRCCM 2000; 162: 2341]

14. Steroid –Resistant Asthma
•Persistentrespiratorysymptoms
•Nocturnalexacerbations
•Chronicairflowlimitation
(FEV
1<70%ofpredicted)
•Noresponsetoshortcourse(7-14days)ofhighdose(>40
mg/day)oralglucocorticoids

15. SRA: Characteristics
•Longerduration;Familyhistory
•Bluntedeosinophilicresponsetosingledoseofcortisol21
succinate
•Increasedcortisolclearance
•Distinctspirometricpatterns:
a.Chaotic:widefluctuationswithnobaselineimprovement
b.Nonchaotic:Littlediurnalvariabilitybutadequate
bronchodilresponse

16. Causes of “Failure to Respond”
in Refractory Asthma
1.Downregulationofbetareceptors
2.Fibrosisorotherstructuralalterationsthatlimitdynamic
responses
3.UnknownfactorsofAO-non-responsivetoBDorCS
4.Altogether,adifferentdisease

17. Difficult Asthma: Physician’s assessment
1.Isthediagnosiscorrect?
2.Doesanyotherdisease,drugortriggercomplicatetheproblem?
3.Istheantiasthmatreatmentadequateandappropriate?
4.Whataboutpatientcomplianceandinhalertechnique?
5.Environmentalcontrolmeasures?
6.Anypharmacokineticabnormalityofthept?
7.Arethedrugsbeingusedreliable,…..?

18. Wrong Diagnosis
•ChronicObstructivePulmonaryDisease
•Cardiacasthma
•Upperairwayobstruction
•Vocalcorddysfunction
•Sleepapnoea
•Localobstructionbytumours/foreignbody
•Hypersensitivitypneumonias
•Infections/Bronchiectasis
•Pulmonaryembolism

19. Casesummary
40M,shopowner
Presentingcomplaints
Recurrentepisodesof‘apnea’:10months
Background
Frequentcough
OccasionalBreathlessnessfor10years
Nodefiniteh/owheeze
h/oloudsnoring,nodaytimesomnolence
Noh/oseizures,abnormalbehavior
Noh/ostridor(butdocumentedinPGI)
[J Assoc Physicians India 2001; 49:488-90]

20. Current Illness: Nov 1999: First episode at night
Uneasiness and difficulty in breathing
Impaired consciousness
Blue
Admitted to ER, intubated,
Recovered with in a day
Subsequently Five admissions to DMC
~ 10 episodes requiring ETT and short term mechanical ventilation
(few hours to 1 day)
Normal in between the episodes

21. No response to anti asthma measures
Very quick reversal on intubation
Normal lung functions in between
Documented stridor
VOCAL CORD DYSDFUNCTION

22. Disease Association
•Rhino-sinusitis/Polyps
•G.E.Reflux
•Obstructivesleepapnoea
•COPD
•Allergicbronchopulmonaryaspergillosis
•Otherinfections
•Churg-Strausssyndrome/vasculitides
•Psychologicalproblems

23. SS31MFarmer
•H/obreathlessness,wheezing(episodic)
mucoid/mucopurulentsputum>10yrs
•Acutesevereattacks
•Poorresponsetoasthmatmt.
•H/oATTinthepast(twice)
•Exam:Extensiverhonchi&crackles
•Haemogram:TLC12000/cum.E8%

24. Allergic BronchoPulmonary Aspergillosis
•Skin test: Immediate & delayed +ve
•Sputum for aspergillus+ve
•Serology +ve
•Treated with oral CS
•Antifungal tmt?
•Maintenance tmt?

25. Asthma -triggers
1.Homeenvironment
•Aeroallergens
•Housedust(mites/others)
•Tobaccosmoke(ETS)
•Solidfuelsmoke
2Infections
3Outdoorexposures:SO
2,Ozone
4Occupationalexposures
5Psychologicalstresses
6Drugs:aspirin,betablockers,ACEinhibitors

26. Aggravating Factors (GER)
•Oldage
•Autonomicdysfunction–loweringofLESP
•Increasedpressuregradientbetweenesophagusandstomach
•Medication:Nicotine,Caffiene,calciumchannelblockers,
atropine,theophylline,nitroglycerineetc.

27. ETS Exposure in Asthma
No Yes
•EDvisits 0.6 0.82*
•Hospitalisation 0.33 0.34
•Ac.episodes 0.6 1.32*
•ParenteralBD 6.0 8.6*
•Workabsence(wks) 3.0 3.6*
•Steroiduse(wks) 8.6 11.3*
•BDuse(wks) 36.3 38.3
*p<0.01
(Jindalet al, Chest 1994)

28. ETS Exposure (Children)
•Parentalsmokingathome
Asthmatics 41% OR 1.78
Nonasthmatics 28% 95%CI1.33-2.31
•Respiratorysymptoms
ETSexposed OR 1.6-2.25
Notexposed
•Asthma(questionnairediag.)
ETSexposed OR 1.78
Notexposed 95%CI1.34-2.36
(Gupta et al, J Asthma 2001)

29. Case of brittle asthma
40M,Bankofficial
Br.Asthma>23yrs
BDP 800mcg/dg
Salbutamol 800mcg/d
Theophylline 600mg/d
Prednisolone 15-20mg/d
Hypertensionin1976(Nifedipine)
PulmTBin1994.GivenATT
Worseningofasthma;acuteepisodes
Prednisoloneincreased40mg/d
Hospitalization–repeated
Guptaetal,IJCDAS1995

30. Worsening of Asthma Control in TB
•Rifampicininduceshepaticenzymesystems
•Increaseinsteroidclearance(45%)
•Decreaseinsteroidbioavailabilitytotissues(upto60%)
(Rifampicinrequirestobeomitted)
•Powell-Jacksonetal1983
•Acocella1978;Udwadiaetal1993

31. Management: Recommendations
1.Confirmthediagnosis
2.Evaluateandtreatconfoundingorexacerbatingfactors
3.Optimizethe“standard”asthmapharmacotherapy

32. 4.Maintenancetreatment
•Labile/Brittleasthma
•Steroiddependent
•Othercomorbidities
5.Specificsituations
•Pregnancy
•Surgery
•Concurrentdiseasesanddrugs
•Occupationalasthma

33. Managing Aggravating Factors
•Tmtofsinusitisandpolyps
•ManagingGEreflux
•Weightreduction
•Sleepdisorderevaluation
•Tmtofpsychologicalstress
•ManagementofVCDifany
•Reducingallergenload,dust,smoke/ETS,pets(etc.)

34. Pharmacotherapy
•Highdose/highpotencyICS
•OralCSatthelowestpossibledose
•Additional1to3controllers
•PEFmonitoring(daily)
•“Asthmaactionplan”–rescuesteps
•Frequentclinicvisits/advice

35. •Usualguidelinesdonotapply
•Testofpatience
•Compliance&doctor-patientrapportiscrucial
•Realisticgoalsoftreatmentshouldbeaimedat
•Evensmallbenefitscanbeimportantifperceivedcorrectly
Management of Type I Brittle Asthma

36. Continuous Subcutaneous Infusion of Terbutaline
(CSIT)
•Describedin1984
•3-12mg/daybyinfusionpump
•50%showmarkedimprovement
•?Mechanismofaction
•Problems
Type I Brittle Asthma
[1. BMJ 1984; 288: 1715-16, 2. Br J DisChest 1988; 82:360-5]

37. Continuous Subcutaneous Infusion of
Terbutaline(CSIT)

38. Othertreatmentmodalities:
•Immuno-modulators
•LABA
•LTA
•Psychotherapy
Type I Brittle Asthma

39. Management of Type II Brittle Asthma
•‘Medic-Alert’card
•Selfadministeredepinephrine“epi-pen’
•Regularcontrollermedications
•Avoidtriggersifknown!

40. Difficult and Brittle Asthma
SUMMARY
•Fewoftheasthmaticsare‘difficult’tomanage
•Carefulexclusionofasthmamimicsandcontrolofexacerbating
factorsissufficientinmostofthem
•Veryfewaretruly‘brittleasthma’whichisperhapsaseparate
phenotype
•Objectivemonitoringisveryimportantinthissubsetofpatients
•Drastictreatmentstepsmayberequired
•Treatmentapproachshouldbe‘holistic’

41. THANK YOU