difficult to treat asthma.pptx

Ppt on difficult to treat asthma

1. Difficult to treat asthma Dr .Emil Mohan Resident Doctor Dept of Respiratory Medicine

2. Overview Definition Clinical Phenotypes Assesment Investigation Management Types of devices

3. Definition Asthma is a heterogenous disease, usually characterized by chronic inflammation. It is defined by the history of respiratory symptoms such as wheeze ,shortness of breath, chest tightness and cough that vary over time and in intensity together with variable expiratory airflow limitation Both symptoms and airflow limitation vary over time and in intensity Triggers:exercise,allergen or irritant,weather change,viral infection

4. Clinical phenotypes Allergic asthma Non-allergic asthma Adult onset (late onset) asthma Asthma with persistent airflow limitation Asthma with obesity

5. Asthma symptom control Adults GINA symptom control tool Asthma control questionnaire(ACQ) Asthma control test(ACT) childhood asthma control scores: Test for respiratory and asthma control in Kids(TRACK) Composite asthma severity index(CASI)

6. GINA ASSESSMENT OF ASTHMA CONTROL IN ADULTS,ADOLESCENTS AND CHILDREN In past 4 weeks Y N Well controlled Partly controlled uncontrooled Daytime asthma symptoms > 2/week none 1-2 of these 3-4 of these Any night walking due to asthma SABA reliever for symptoms > 2/week Any activity limitation due to asthma Risk factors Medications: high SABA use, Other medical condition: obesity, rhinosinusitis, GERD, food allergy, pregnancy Exposures: smoking, e-cigarettes, air pollution Lung function: low FeV1 <60% predicted Type 2 inflammatory markers: high blood eosinophil, elevated FeNO Ever intubated patient for asthma

7. Difficult to treat asthma Difficult to treat asthma is asthma that is uncontrolled despite prescribing of medium or high dose ICS-LABA treatment or that requires high dose ICS-LABA treatment to maintain good symptom control and reduce exacerbations. Severe asthma is asthma that is uncontrolled despite adherence with optimized high dose ICS_LABA therapy and treatment of contributory factors, or that worsens when high dose treatment is decreased.

8. Difficult to treat asthma It doesn’t mean a difficult patient Incorrect inhaler technique Poor adherence Smoking Co-morbidities Incorrect diagnosis

9. OMALIZUMAB Dosage:150mg every 4 weeks for 12 weeks Subcutaneous route Adverse effects:  injection-site reactions (45%), viral infection (23%), upper respiratory tract infection (20%), sinusitis (16%), headache (15%), and pharyngitis (11%),  Churg-Strauss vasculitis. MEPOLIZUMAB 100 mg SC q4wk BENRALIZUMAB 30 mg SC q4weeks for the first 3 doses, THEN q8weeks thereafte r

10. Alternative diagnosis Dyspnea : COPD,obesity , cardiac,deconditioning Cough: inducible laryngeal obstruction(VCD),upper airway cough syndrome(post-nasal drip), GERD,bronchiectasis , ACE inhibitors Wheeze: obesity, tracheobrochomalacia , COPD Rhinosinusitis and gastro esophageal reflux disease are most common disorders associated with poorly controlled asthma( Fisman p.711)

11. Vocal cord dysfuntion Present with stridor and wheeze Escalation in asthma therapy Investigation nasoendoscopy to observe vocal cord movements and if confirmed patinets should be weaned off corticosteroids Speech therapy intervention Bromchoscopy to exclude tracheo broncho malacia

12. Subotimal adherance Upto 75% patients Ask about frequency of use Barriers to medication use;cost and concerns about necessity, side effects Electronic inhaler monitoring

13. comorbidites Anxiety and depression Obesity Deconditioning Chronic rhinosinusitis Inducible laryngeal obstruction GERD COPD OSA Bronchiectasis Cardiac disease Kyphosis due to osteoporosis

14. Modifiable risk factors and triggers Smoking environmental tobacco exposure Allergens Indoor and outdoor pollution Molds and noxious chemicals B- blokers /NSAIDS

15. Regular or over use of SABA B-receptor down regulation and reduction in response >3 canisters /year – increased risk of emergency hospitilization >12 canisters /years- increased risk of death Risks are higher with nebulised SABA

16. Anxiety , depression and socioeconomic problems Medication side effects; dysphonia , thrush Drug interaction: adrenal suppression with use of p450 inhibitors such as itraconazole.

17. Brittle asthma Some patinets have unstable disease with rapid variations in lung function that lead to recurrent and severe attacks despite appropriate treatment Type I brittle asthma,where there is a sustained pattern of chaotic peak flow variability on a daily basis Type II brittle asthma where asthma symptoms and lung function are well controlled ,but there ae abrupt and unpredictable falls in peak flow that may be catastrophic and result in sudden death Treament:portable epinephrine autoinjector

18. Pressurised MDI most frequent errors made by patient shaking the device before the second puff separating inhalation of each dose by 15 to 30 seconds pressing the canister correctly to release the medication advantages Disadvantages Compact and portable High oropharyngeal deposition Multi-dose Difficulty in hand-mouth coordination Quick treatment time Cold freon effect Drug in sealed canister Difficult to assess empty canister inexpensive

19. Dry powder inhaler Advantage Disadvantages Compact and poratable Need adequate inhalation flow Quick treatment time High oropharyngeal deposition Breath actuated function removes need for coordination Humidity can cause drug degradation Propellent free devices that contain finely powdered drug particles bound into loose aggregates Breath actuated in operation Rely on patient’s respiratory efforts Two types: single dose delivery systems that require drug to be individualy loaded Multi dose systems that deliver drug that is metered from a powdered reservoir

20. nebulizers Ultrasonic nebulizer Utilize the vibration from a piezoelectric crystal ata high frequency to produce aerosol clouds for inhlation from the liquid drug Smaller ,less noisy but expensive not effective in nebulizing liquid suspensions Jet nebulizers Use eithercompressed gasor an electrical compressorto generate aerosolized particles through a narrow venturi opening to produce aerozolised particles within the nebulizing chamber

21. References Fishmans text bookof pulmonary diseases   Global Strategy for Asthma Management and Prevention 2022 guidelines