Asthma Training Module - 2013

8/12/2019 Asthma Training Module - 2013

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Asthma Training Module

based on

Asthma By Consensus

IAP

National Guidelines for theManagement of Childhood Asthma

2013 Update


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Asthma Training Module

Protected under copyright.

Any further usage of this presentation implies that you have read and

accepted the terms of use of this module.

The material is meant for the training of a registered medical

practitioner only.

The module provides overall guidelines for managing childhood

asthma. The decision for individual case management should be

based on their own merit.

2013 Update


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Todays tasks

Must know

Basic pathophysiology

Diagnosis of asthma Long term management

Managing acute attacs

!emonstration time


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"at#h for these sym$ols

This symbol calls for

interaction with the speaer

This symbol indicates a Parent"ducation Point

PEP Talk

interact !


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Basi#s % $ri#k and mortar &


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Asthma

$haracteri%ed by

Airway

#hroni# inflammation

hy'er res'onsi(eness o$stru#tion%re(ersi$le


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IN!)C*+,Allergens

Maternal smoing' $hemicals'

Air pollutants' (irus infections

IN-.AMMATI/N

T+IGG*+,")ercise

$old Air' *+2

Particulates

(irus infections

,0MPT/M,

Airway,yper-responsiveness Airflow Limitation

Geneti# 'ro'ensity


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Inf lammation in asthma

Chroni# inflammation

,tru#tural #hanges

,u'erim'oseda#ute

inflammation

Time

Airwayremodeling


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!iagnosis of asthma

The story begins00


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Clini#al e(aluation

Ascertain diagnosis

1dentify #o%mor$id #onditions

Thin of alternate diagnosis

rade se(erity

1dentify triggers


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.ets look at some #ase histories

!iagnosis of asthma


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Case11Ar'it

& year old Arpit was seen for recurrent cough

for about 3 year. ,is mother reported that he

fre5uently had colds which went to the chest

"hat further 2uestions will you ask3

interact !


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Ask for11

6ecurrent #ough3 6ecurrentwhee4e3

6ecurrent $reathlessness3

A#ti(ity5stress indu#ed cough7whee%e8 No#turnalcough8

Tightnessof chest8

Symptoms of airf low obstruction


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And 2ualifiers of asthma

+e#urrent e'isodesof airflow obstruction

with several of the following9

6 Afe$rileepisodes

Personalatopy or -amily h5o ato'y7 asthma

No#turnale)acerbations

,tress5A#ti(ity induced symptoms

Triggerinduced symptoms

,easonale)acerbations

+elief with $ron#hodilators: oral steroid


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Ar'it #ontinued

"hat do you e7'e#t to find when you

e7amine Ar'it3

interact !


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.ook for11

,igns of airf lowo$stru#tion

enerali%edwhee4e

Prolonged e7'iration

$hest hy'erinflation

/ther features ofato'y

Ato'i# dermatitis 5

*#4ema

Allergi# rhinitis 5

#on8un#ti(itisIn the interval period, chest examination may be normal


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Ar'it #ontd

Arpit 1 ased0

"hat is the rele(an#e of this history3

interact !


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Ascertain diagnosis

Identify #o%mor$id #onditions


rade se(erity

1dentify triggers


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Co mor$id #onditions

Allergi# rhinosinusitis

*nee%ing in the morning' nasal itching

6unning 7Bloced nose' snoring' mouth breathing

Adenoidal hy'ertro'hy

$olds' ear infections

Bloced nose' snoring' mouth breathing

Gastroeso'hageal reflu7 disease 9G*+!:

?octurnal cough 7 vomiting

Theophylline 7 +ral @2 agonist usage

PEP Talk


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.ook for11

*igns of allergic rhino-sinusitis

?asal mucosa edema' pale or violaceous

$lear nasal discharge 7Bloced nose

Post nasal drip

$obblestone pharyn)


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Ascertain diagnosis

1dentify co-morbid conditions

Think of alternate diagnosis

rade se(erity

1dentify triggers


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Think of alternate diagnosis&

If 'resentation is $elow si7 months of age

Consider

(irus associated whee%e

Aspiration syndromes e.g. " reflu) disease

$ongenital airway anomalies

$ongenital heart disease Cloo for murmurs


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If lo#ali4ing signs are 'resent

Ene5ual air entry

Enilateral emphysema

6adiological locali%ation

Considerairway obstruction

Foreign body aspiration

$ongenital anomalies



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"ith 'ersistent res'iratory sym'toms

Consider

6hino sinusitis

Foreign Body

Tuberculosis

Pertussis



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If unusual features 'resent

Failure to thrive

Multiple multifocal infections $lubbing

$onsanguinity

Malabsorption

Consider $ystic fibrosis

Primary ciliary dysinesia

1mmunodeficiency



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Ar'it1 #ontinued

;ow will you 'ro#eed to in(estigate

Ar'it3

interact !


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Typical history

$B$ may show eosino'hilia


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Breaking the news&

=Arpit has asthma> 1 told the mother. *he looed

bewildered. =?obody told me that> she said.

=My previous doctor called it Gallergic bronchitis she e)claimed' =AsthmaH And no

breathlessness80 Are you sure8>

;ow do you #on(in#e this an7ious lady3

interact !


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The asthma i#e$erg PEP Talk

Breathlessness 0 the tip

6ecurrentcough

6ecurrentwhee%e

?octurnalc

ough

Tightnessofchest

All Asthma !oes Not "hee4e


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Arpit


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,'irometry 5P*-+5Allergy testing

,'irometry

when clinical diagnosis is in doubt older children

"ffort dependent- proper techni5ue critical

Peak flow

has a limited role in diagnosis

Best used for monitoring

Allergy testing 5 Ig* le(els 5 +A,Thave no role in diagnosis

PEP Talk

Demonstration time


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Coming to terms

=1 now understand what you have said so far0>

said Arpit

,im'lify the story for her

interact !

P"P Tal


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;ealthy Airway Asthmati#Airway

*mooth muscle

"pithelium

Clining

Alveolar partition

*mooth muscle

constriction "pithelial shedding 7

damage

1nflammationand swelling

Mucus and plasmaoutpouring

Asthma #om'onentsP"P Tal


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1ts December. Amit' Arpit


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A#ute Bron#hiolitis

First episode of whee%ing in a young child Cup

to 2 yrs

*tarts with cory%a' usually with fever

$lustered in winter and rainy months

?o atypical features

PEP Talk


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The first time whee4er

I ! episodes of airflow obstruction

A?D

a family h7o asthma7atopy or personal

h7o atopy

"ollow up #or other $uali#yin #eatures

be#ore assinin a dianosis o#

asthma

PEP Talk

PEP T lk


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+isk fa#tors for Asthma

+ther atopies

atopic dermatitis

Allergic rhinitis 7 conJunctivitis

Asthma 7 atopy in family

sibling - dou$lesris

one parent - dou$lesris $othparents -tri'lesris

PEP Talk

As compared to

general population


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The early whee4er

1ndu' who is Arpit


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*'isodi# 9(iral: "hee4er

Associated with a febrile viral respiratory

infections

Discrete episodes of whee%ing

Kell between episodes

Esually no personal or family history of atopy


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Another early whee4er

*ushil' > yearsold' has been getting recurrent

cough' cold and whee%ing with fever since8oining

the #re#heas well. ,e also starts whee%ing when

e7'osed to #igarette smoke or his visit to his

farmhouse.

$ould this be asthma8

interact !


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Multi trigger whee4er

Triggers apart from viral E6T1

Afebrile episodes also present

Discrete episodes

+ften symptomatic between episodes

*trongly suspect asthma when associated

with personal and family history of atopy

#!


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)nder fi(e whee4ers% a mi7ed $ag

All that whee%es is ?+T asthma

"pisodic Cviralwhee%er Multi-trigger whee%er Khee%er with atypical features

Acute Bronchiolitis

##


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)nder ? whee4ing % summary


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,ummary so far11

Diagnosis is #lini#al

6ecurrent episodes of airflow obstruction are present

Airway obstruction is reversible

Alternative diagnoses are e)cluded

$o-morbid conditions are identified

The under-; whee%er is a mi)ed bag


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Managing asthma%long term

Managing under ? whee4ing

*ome pharmacology and

essentials of inhaled therapy.


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!rugs

+elie(ers

Esed in a need basedmanner for treatment of

bronchospasm and to

relieve acute attacs

Controllers

Esed on daily long termbasis for control of

inflammation and to

prevent further attacs


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Controllers

/ral

.eukotriene antagonists

Theo'hylline % ,+

/ral 'rednisolone

Inhaled

Corti#osteroids9IC,:

.ong a#ting inhaled

>%agonists 9.ABA:


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Inhaled Corti#osteroids

*stimated e2ui'otent daily doses of IC,

Children @ > years

Drug Low dose

Cg

Medium dose

Cg

,igh dose

CgBudesonide 344-244 244-#44 #44

Fluticasone 344-244 244-;44 ;44

Beclomethasone 344-244 244-#44 #44


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Inhaled Corti#osteroids

*stimated e2ui'otent daily doses of IC,Children > years

Drug Low dose

Cg

Medium doseCg

,igh dose

CgBudesonide 344-#44 #44-/44 /44

Fluticasone 344-2;4 2;4-;44 ;44

$iclesonide /4-3&4 3&4-!24 !24Beclomethasone 244-;44 ;44-3444 3444


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"hy ,teroids 3

Chroni# inf lammation

,tru#tural #hanges

,u'erim'oseda#ute inflammation

Time

A

irwayremodelin

g

Chroni# inflammation

,tru#tural #hanges

A#uteinflammation

Airway

remodeling

,ystemi#steroids

Time

Inhaled steroids

PEP Talk


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Inhaled steroids%'ra#ti#e 'oints

Anti%inflammatory effe#tevident in 3-2 wees.

Local adverse effects thrush7dysphonia minimi4ed $y

s'a#er5gargling

Esually re5uired inhaled doses- negligi$le systemi#effects

Prolonged high dose- monitor growth and eyes Ccataracts.

PEP Talk

In practice, most children need low doses

PEP Talk


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Uncontrolled asthma is more li%ely to causerowth #ailure than usually needed doses o#

inhaled steroids

PEP Talk


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.eukotriene antagonists% 'ra#ti#e 'oints

Kea antiinflammatory effect compared to 1$*

Add-onin moderate 7severe asthma

1nferiorto1$*in mild persistent asthma

Eseful in ")ercise induced asthma

May be used when concomitant allergic rhinitis

Monteluast approved for & months of age


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,+%Theo'hylline% 'ra#ti#e 'oints

Anti%inflammatory5immunomodulator

$urrently used as a#ontroller

Esed as adJunct to inhaled steroids Colder children

&o role o# syrup #ormulations

Monitor ad(erse effe#ts- clinically and blood levels

Beware f lu#tuationsin levels - fever' anti TB

treatment' anticonvulsants' 5uinolones' macrolides


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.ong term oral steroids% 'ra#ti#e 'oints

Ese limited to severe persistent asthma

Minimal possible dose

Alternate day morningdose is preferred Cto reduce ,P a)is

suppression.

Prednisolone - best option

Monitor growth Cheight7weight' eyes' sin' bone density'

immune suppression' ,PA suppression.

d li i h l d


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!rug deli(ery % inhaled route

1nhalation Device Delivery

MD1 with spacer 34- 3;N

Metered dose inhaler CMD1 ; - 34N

Dry powder inhaler CDP1 ; - 34N ?ebuli%er 3- ;N

PEP Talk


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+ole of s'a#ers

"liminate need for hand - breath #o%ordination

+edu#e lo#al side effe#tsof inhaled steroids

Im'ro(e drug deli(ery

!ilute tasteof inhaled sprays.

"liminate #old freoneffect Cwith $F$

PEP Talk

'hen usin ()Is, *pacer is a must

f


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Ty'es of s'a#ers

*mall volume vs large volume

(alved vs non valved

Polyamide vs polycarbonate

Use any spacerbut

USE A SPACER

+ l f kPEP Talk


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+ole of mask

*pacer with well fitting mas

Below O ! years or anyone who cannot breathe

consciously through mouthpiece of spacer.

*pacer alone

Above O ! years' or +nce a child learns to breathe through mouthpiece

mas should be removed.


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;ow do you initiate inhaled thera'y3

interact !

h


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The D ste's

3. ")plain advantages of inhaled therapy

2. Dispel myths and fears

!. *elect an appropriate device

#. Demonstrate how to use the selected device

d f i h l d h

PEP Talk


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Ad(antages of inhaled thera'y

Inhaled /ral

6oute Direct 1ndirect

Dose *mall ,igher

+nset of action 6apid *low

Adverse effects Mild-none reaterSmallerdose, targetdelivery, quiceraction, lessersidee##ects

Th D


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The D ste's

")plain advantages of inhaled therapy

2. Dispel myths and fears



!i lli h d fPEP Talk


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!is'elling myths and fears

1s inhaler therapy Gstrong


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The D ste's


Dispel myths and fears



Th i ht d iPEP Talk


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The right de(i#e

$riteria for selection

Age

$ontroller use

Acuteepisodes


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PEP Talk

, l ti th i ht d i


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$ontroller regimen

Moderate to high dose 1$* Ese MD1 spacer instead of DP1 even in

older children

,ele#ting the right de(i#e

,ele#ting the right de(i#ePEP Talk


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,ele#ting the right de(i#e

Acute episodes

,ome - MD1 spacer mas 7 DP1

,ospital - MD1 spacer mas

- ?ebuliser in severe episodes

!o not use !PI in moderate"se#eree$acerbations

Th D t


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The D ste's


Dispel myths and fears

*elect an appropriate device

#. Demonstrate how to use the selected

device

Demonstration time


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Managing the under ? whee4er

Amit 9re#a':


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1ts December. Amit' Arpit


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Bron#hiolitisManagement

A#ute e'isode

+)ygen in severe cases

+ral 7 nebulised @2 agonists

?ebulised adrenaline is preferred

*ymptomatic therapy

.ong term thera'y

?ot indicated

Indu 9re#a':


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Indu 9re#a':% the early whee4er

1ndu' who is Arpit


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*'isodi# 9(iral: "hee4erManagement

A#ute e'isode

+)ygen in severe cases

+ral71nhaled @2 agonists

*teroids when severe or with associated ris factors

.ong term thera'y

1f severe or fre5uent episodes C once a month Daily 1$* may be beneficial

1ntermittent LT6A- Limited effect

,ushil 9re#a':


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,ushil 9re#a':E the multi trigger whee4er

*ushil' > yearsold' has been getting recurrent

cough' cold and whee%ing with fever since8oining

the #re#heas well. ,e also starts whee%ing when

e7'osed to #igarette smoke or his visit to his

farmhouse.

*hould he be treated as asthma8

interact !

M lti t i h


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Multi trigger whee4erManagement

A#ute e'isode +)ygen Cin severe cases

Treat with inhaled or oral bronchodilatorsdepending on severity.

@2 agonists are main stay of therapy

Ese steroids early' particularly if personal 7family history of atopy present

Multi trigger whee4er


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Multi%trigger whee4erManagement

.ong Term Thera'y A trial of 1$* C#44 mcg per day

1f no clear benefit within #-& wees of initial therapy $onsider alternative diagnoses

1f good response' give for /-32 wees and stop.

1f recurrence on stopping' label and treat as

asthma LT6A - a less effective alternative


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Ba#k to long term management ofasthma

0and the story of Arpit and his

friends

Management GoalsPEP Talk


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-reedomfrom ,ym'tomsincluding nocturnal cough

A#uteasthma atta#ks

*mergen#ydoctor7hospital(isits

Minimal need for relie(ers

Minimal ad(erse effe#tsfrom drugs

Normal

Physi#al a#ti(ityincluding participation in sports

Growth$harts

.ung fun#tion

Management Goals

Management strategy


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Identifyand a(oidtriggers

)secontrollers

Treatacute attacs with 6elievers

*du#atefamily regarding management

Monitorand modify therapy to maintain control

Management strategy

+e#a'itulating


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+e#a'itulating #lini#al e(aluation

Ascertain diagnosis



Grade se(erity

1dentify triggers

Grading se(erity


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Grading se(erity

%#er a period of time

helps to decide regarding need and choice of

controller medications for long term control

At a point in time

helps to decide regarding the level of care and drugs for anacute e)acerbation

Grading se(erity


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Grading se(erity

,ym'tomsof airf low

o$stru#tion

Night time

sym'toms

Peake7'iratory

f low 9P*-:

Intermitte

nt

QI once a wee

Q

Asym'tomati#

andnormal

$etweenatta#ks

Q I twice a

month

Q /4 N of

personal bestQ I 24 N diurnal

variationRR

FF &ormal diurnal variation . /10 in " values!

owest " levels are seen on wa%in and hihest levels about 12 hours later!

1

Grading se(erity


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Grading se(erity

,ym'tomsof airf low

o$stru#tion

Night time

sym'toms

Peake7'iratory

f low 9P*-:

Mild

'ersistent

Q once a

wee butI once a day

Q twice a

month

Q /4 N of

personal bestQ 24-!4 N

diurnal variation

2

Grading se(erity


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,ym'tomsof airf low

o$stru#tion

Night time

sym'toms

Peake7'iratory

f low 9P*-:

Moderate

'ersistent

Q once a day

Q Attacs

affect activity

Q once a

wee

Q &4 - /4 N of

personal best

Q !4 N diurnal

variation

3

Grading se(erity

Grading se(erity


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,ym'tomsof airf low

o$stru#tion

Night time

sym'toms

Peae)piratory

flow CP"F

,e(ere'ersistent

Q $ontinuous

Q Limited

physical

activity

Q Fre5uent Q I &4 N of

personal best

Q !4 N

diurnal

variation

4

Grading se(erity

Grading se(erity %sim'lified


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Grading se(erity %sim'lified

-re2uen#y of sym'toms

daily7weely7 monthly7 or less

!uration of sym'toms

day or two7 wee or so7 or more

Grading se(erity % sim'lified


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Grading se(erity % sim'lified

Inter(al $etween sym'toms

no symptoms7 some cough7 nocturnal cough

,e(erity of sym'toms

,ospitali%ations7 1$E

Asthma


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AsthmaTreatment

,te' % Intermittent

1nhaled 7 oral short acting @2 agonists asre5uired

?o controllers

A(oid triggers

Asthma


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,te' % *A @2 agonists prn

,te' > % Mild Persistent

Preferred treatment9

Low dose 1$*Alternative treatment

Leuotriene antagonists

A(oid triggers Treat a#ute e'isodes

AsthmaTreatment


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Asthma


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AsthmaTreatment


,te' > % Low dose 1$*


,te' H Add LABA

,te' D % ,e(ere Persistent


Medium7,igh dose 1$* LABA

If un#ontrolled add +ral steroid7 Anti-1g"


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?ow let


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;istory re#a'

& year old Arpit was seen for recurrent cough sinceabout 3 year. +n en5uiry' the cough bothered him

once every two months lasted for three to four

days. The cough was much more in the earlymorning hours.

;ow will you grade and treat Ar'it3

interact !

Grading se(erity


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Arpit has intermit tent asthma

Grading se(erity

The #ru7 of the matter


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The #ru7 of the matter

C%&'R%((ERS ))

%r

&% C%&'R%((ERS ))

'hat is the question*

No #ontrollers


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No #ontrollers

Intermittent asthma

1nfre5uent Cmonthly or less'

short duration C2-! days'

mild episodes

+owe#er, se#ere e$acerbations, e#en if infrequent,qualify for controller therapy

Asthma


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AsthmaTreatment 9re#a'11:

,te' % Intermittent

1nhaled 7 oral short acting @2 agonists asre5uired

?o controllers

A(oid triggers

Clini#al e(aluation1


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Clini#al e(aluation1

Ascertain diagnosis



rade severity

Identify triggers

Triggers 5 're#i'itantsPEP Talk


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Triggers 5 're#i'itants

Allergens

Irritants

Pre#i'itants

(iral infections

Inhaled allerens4 irritants and viral

in#ections are the most important triers

IrritantsPEP Talk


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Irritants

,moke Avoidto$a##o smoke' agar$attis' fumes from kerosene

sto(e' wood' cow dung

-ine dust

Avoid chal' sprays' talcs

,trong odors

Do not use strong perfumes

Mos2uito re'ellent mats #oils

Advise use of mos5uito nets' long clothing

AllergensPEP Talk


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Allergens

!ust mite antigen 6emove #ar'ets 5 u'holstery

Cotton sheetsrather than woolens.

")pose mattresses to sunlight "ash soft toysperiodically

Co#kroa#h antigen

Preserve unused cooed foods in covered

containers

Allergens


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g

Molds and s'ores Attend to dam' walls7 leaages. $lean air%#onditionerfiltersmonthly

Animal dander 5Pollen Avoidf lowers5'erfumesindoors *tayindoors during harvesting season.

Pets Bathepets weely Mae them sleep outdoors


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=*hould we change our home and move to a dry

climate8> ased the an)ious granddad.

=Khat food stuffs should we avoid8> ased the

grandma.

Khat will you advise these senior citi%ens8

interact !

PEP Talk


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)iet . over.emphasi5ed

6 eneral avoid list to all patients is

irrational!

6ddress the environment

rather thanchane the address

Ar'it #ontd


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'

A year later' Arpit


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y

6sthma is a dynamic condition!

6t presentation, asthma se#erity is raded touide introduction o# medication!

7n therapy, the titration o# medications is basedon the assessment o# asthma control!

Assessment of Asthma Control


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.e(el of Control

Chara#teristi#

Controlled

9All of thefollowing:

Partly Controlled

9Any measure'resent in anyweek:

)n#ontrolled

!aytime sym'toms ?one Ctwice orless7wee

More than twice7wee

Three or morefeatures of'artly#ontrolledasthma 'resent

in any week

.imitations ofa#ti(ities

?one Any

No#turnalsym'toms5awakening

?one Any

Need for relie(er5

res#ue treatment

?one Ctwice or

less7wee

More than twice7wee

.ung fun#tion 9P*-or -*J:

?ormal I /4N predicted orpersonal best Cifnown

*7a#er$ations ?one +ne or more7yearR +ne in any weeS


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Asthma %treatment


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1f control is not achieved with current

regimen' then treatment is to be stepped up

until control is achieved.

1f asthma is partly controlled' then increase

in treatment should be considered subJectto safety and cost

Ar'it#ontd


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'

Arpit is 'artly #ontrolled.

,e needs stepping up of therapy Cfrom

step to step >

,e now needs regular controller therapy.


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*anJana has moderate 'ersistent

asthma.

Asthma


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Treatment 9+e#a':



,te' H % Moderate Persistent


Low dose 1$* inhaled LABA Medium dose 1$*Cin children I ; years

Alternati(e treatment9

Low dose 1$* Leuotriene antagonist 7 *6 theophylline C ;years

,an8ana 11 #ontd


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8

*anJana followed up # wees later. *he was not better. 1 wondered whyH=Kho gives the medicines to *anJana> 1 ased her mom8

=1 taught her initially> she replied =now she is old enough to tae them on

her own>.

=Are you8> 1 ased *anJana. *he coyly looed away000

"hat do you think is going wrong3

interact !

+easons for non%adheren#ePEP Talk


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1ntentional Feel better CGcured


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*he was seen si) wees later. *he was now

adherent and the mother was supervising therapy.

*he still woe the night coughing and whee%ed

fre5uently.

"hat would $e your a''roa#h now3

interact !


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I# a child re$uires

rescue steroids 4 82 . aonists #re$uently,

explore reasons #or poor control!

Poor #ontrol of asthma


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,ummary

6ule out alternate

diagnosis $o morbid conditions

$hec Diagnosis

$hec the following

Triggers Adherence FunctionalThe !DsDose

Device

Delivery

Poor #ontrol of asthma


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6ule out D7D$o morbid conditions

$hec Diagnosis

$hec the following

Triggers

T;* DT; !

Adherence FunctionalThe !DsDose

Device

Delivery

*tep up !rug dose 7 regimen

Trial of rescue steroid

,ummary

Asthma


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Treatment 9+e#a'11:




,te' H Add LABA

,te' D % ,e(ere Persistent


Medium7,igh dose 1$* LABA

If un#ontrolled add +ral steroid7 Anti-1g"

A$$as


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Abbas is a year old boy with moderate 'ersistentasthma on therapy. ,e reported a nocturnal cough and

snee%ed every morning. ,is mother was regular with the

inhalers and the techni5ue was appropriate as checed in

the clinic.

"hat #ould $e wrong now3

interact !

Co%mor$id #onditions 9re#a'11:


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Allergi# rhinosinusitis "6

+besity

Allergi# rhinitis


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Moderate%se(ereone or more items

abnormal sleep

impairment of daily

activities' sport' leisure

abnormal wor and school

troublesome symptoms

Persistent # days per wee

and # wees

Mild

normal sleep

U no impairment of daily

activities' sport' leisureU normal wor and school

U no troublesome symptoms

Intermittent I # days per wee

or I # wees

in untreated 'atients

Allergi# rhinitis!rugs a''ro(ed for #hildren


130/204

To'i#al?asal steroids

Mometasone furoate U

Fluticasone furoate9 2 years

Fluticasone propionate9 # years

Budesonide & years

?asal Antihistaminics

A%elastine9 ; years

+lopatadine 32 yrs

/ralAntihistaminics

$etiri%ine U Desloratadine9 &

months of age

Loratadine9 2 years

Fe)ofenadine9 & years

LT6AMonteluast9 & months of

age.

Allergi# +hinitis Treatment


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Intermittent Persistent



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astroesophageal reflu) disease C"6D

May cause whee%ing 7 e)acerbate underlying asthma

especially in 2 subgroups9

Difficult-to-control asthma Voung infants with severe recurrent whee%ing episodes

1nvestigate with "6 scintiscan72# hour esophageal

p, monitoring or both



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astroesophageal reflu) disease C"6D Trial of Anti%reflu7treatment with PP1 can be given in such

cases for /-32 wees

Although recent data has failed to show a therapeutic benefit

in children with severe asthma and proven "6D.

+ral bronchodilators7theophylline to be avoided



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/$esity

Diet 7 life style modification

Physical activities

-ollow u' 1 1 11


135/204

Khenever *anJana' Abbas or Arpit visit your

office'

"hat will you ask or look for3

interact !

At #lini# %follow u'


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,ym'toms and signs

bronchodilator usage

nocturnal symptoms

school absenteeism

limitation of activity

growth monitoring

P arental #on#erns

+egimenprescribed

I nhaler thera'y%!eli(ery5!rugs

C om'lian#e 9Adheren#e:

* n(ironmentcontrol


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+n a subse5uent visit' *anJana' he

ased

*anJana


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"ssentially#lini#al

P*-+if

Traina$lei.e. age above ; years

Tena$lei.e. well initiated to therapy

Afforda$le

,'irometry if

Age Kyears Afforda$le A(aila$le

Demonstrationtime

Cases


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*anJana' Arpit and Abbas ept well on their

regimes.

+n the ne)t visit' the parents en5uired =what

ne)t8>

"hat will you answer them3

interact !

"ell #ontrolled asthma,te''ing down treatment


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,te''ing down treatment

Khile using 1$* alone Cmed to high doses

?LN reduction at H months interval

Khile using 1$*LABA-

reduce 1$* alone by ?LN while continuing LABA.

Khen control is maintained reduce 1$* till low dose is reached

when LABA can be stopped

Khen control achieved at low dose 1$* alone

switch to once a day therapy

"ell #ontrolled asthma,to''ing treatment


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,to''ing treatment

Good #ontrolcontinues on low dose 1$* O 3 year

,to'controllerregimen

Trigger a(oidan#econtinues

"ritten ;ome management 'lanfor acute episodes C

,te'

regime

Follow up H%K monthlyfor %> years

$ounsel regarding 'ossi$le future resum'tionof

controller' if recurrences.

"hat ne7t 3


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*anJana stays well. At one of the visits the

parents as

=1s she now cured8>

"hat will you tell the 'arents3

interact !

Natural history PEP Talk


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6e-emphasi%e that drugs #ontrolbut do not

cure'

As asthma among children often remits'control can be considered

as good as cure.

1dentify those at risk for 'ersisten#e

Natural history of asthma PEP Talk


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+isk fa#tors for asthma 'ersisting into adulthood

-emale *#4ema

+nset after ageof ! years

,e(eredisease

Parental historyof atopy 7 asthma

Case


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*ailesh is a year old with mild 'ersistentsymptoms. =,e' says the

mother. 1 confirm this seeing his past records over two years.

"hat do you #on#lude and how will you manage

,ailesh3

interact !

,easonal asthmaManagement


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Management

Daily controller regimen

*tart a few wees 'rior to anti#i'ated onsetofsymptoms

continue through the season

"ncourage indoor activities during such

seasons

Case


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Daphin plays interschool basetball. "very time he

starts his game' he is whee%ing within minutes.

=Kill 1 be able to play the finals8> he ass an)iously

"ill you let him 'lay and what will you ad(ise

him3

interact !

PEP Talk


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Daphin has *7er#ise Indu#ed Asthma

PEP Talk


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Daphin has *7er#ise Indu#ed AsthmaBron#ho#onstri#tion

xercise

.the only trier the asthmatic child should

conquer and not avoid

*7er#ise indu#ed asthma


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*cenarios

$hild has asthma

e)ercise is one o# the triers for bronchoconstriction

$hild does not have asthma

e)ercise is the only trier for bronchoconstriction

*7er#ise indu#ed asthmanon 'harma#ologi#al a''roa#hes


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non 'harma#ologi#al a''roa#hes

$hoice of game

?ose breathing

Avoid e)ercise on cold mornings

*low deep breathing

Karming up

*7er#ise indu#ed asthmaPharma#ologi#al ad(i#e


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Pharma#ologi#al ad(i#e

-or #ontrol *uitable controller regimen Cconsider LT6A7 LABA

with 1$* 1$* LT6A 7 1$* LABA

1n addition 9 1nhaled *A @2 agonist - 3;-!4 min before planned

e)ercise.

-or treatment 1nhaled *A @2 agonist

Case


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Mrs 6eddy had heard of your interest in asthma.

*he came you asing to confirm the diagnosis.

*he en5uired whether homeopathy would have

an answer. *he had also heard about fishtherapyH

"ill you lose your tem'er3

interact !

+ela71and e7'lain PEP Talk


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Limited scientific literature on acupuncture'

homeopathy

Benefits of Voga

?o scientific literature on Gfish therapy< etc

Current e(iden#e does not suggest $enefits1

Case11


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Mrs *hah brought her / year old. *he had come on avery busy clinic day. Vou 5uicly tell her the diagnosis

and advise her the inhaled steroid regime. *he does

not follow up. Vou diagnosed right 'res#ri$ed right'

but later learn that they have gone to a colleague for asecond opinion and are continuing with himH

"hy did you lose this 'atient3

interact !

The need of the hour&


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6t the #irst meetin ive your patient

your time and not 9ust yourprescription!

Parent *du#ation Points


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3. ?ature of disease-need for $ontrollers2. Drugs control' do not cure

!. 1nhaler therapy issues

#. *teroid issues

;. Esage of inhaler device and regime

&. Time taen to note benefit

. Triggers

/. Diary of events

. Acute home care

34. ?eed for follow up

+: +& C7((6&)(&+*


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Managing a#ute e'isodes

*ome Pharmacology

+elie(ers


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,hort%a#ting >%agonists

*albutamol

TerbutalineNon sele#ti(e %agonist

Adrenaline

Anti#holinergi#s

1pratropium bromide

,teroids

Methyl7anthines

C*elect situations

Magnesium sul'hate

Inhaled >%agonists


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!rugs of #hoi#e.

*albutamol 7Levo-*albutamol7 Terbutaline are similar.

*evere acute episode nebuliser preferred

Dose - 4.3; mg7g7dose Cminimum dose 2.;mg

or say as rough guideline9

I # years - 4.; ml of salbutamol nebuliser soln

# years - 3 ml of salbutamol nebuliser soln

Dilute in salineonly' ?"("6 distilled water

Beware of hy'okalemiawith high dose nebuli%ation.

+es#ue ,teroids


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*arly usage- reduces morbidity7 hospitali%ation

/ral 'rednisolone3 mg7g for !- days.

?o tapering needed 7 ?o adverse effects

In8e#ta$lesdo not confer 5uicer benefit. ,ydrocortisoneC # mg7g 5 &hr or

1( Methylprednisolone C3-2 mg7g 5&hr

1( 7 1M De)amethasone C4.3 4.2 mg 7 Wg 5 & hr

if patient unable to tae orally Cdrowsy7distressed7vomiting

;igh dose inhaled 5 ne$ulised steroids%not 'ro(en

Anti#holinergi#s


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I'ratro'ium $romide

Additi(eeffect to @2 agonist in acute severe asthma

Ne$ soln E L1? ml @yr ml yr

C$ompatible with @2 agonist solution.

Limit use to >D hoursto prevent atropine lie effects

Ce.g.fever

Magnesium ,ul'hate


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Me#hanism of a#tion9 acts through a different pathway C calcium channel in

the airway

has immediate bronchodilator and mild anti

inflammatory effects

!ose9

>?%?L mg5kg IJ slow infusion dissol(ed in ?L ml ,alineo(er HL minutes 9total ma7imum dose%>g:

To7i#ity

Tachycardia7bradycardia' hypotension' muscle weaness at

higher serum level

Amino'hylline


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6etains its role as reliever in acute severe attacs

improves diaphragmatic contractility

mucociliary function

inflammatory modulation

!ose9

Loading dose ; mg7g slow diluted IJ $olus with ? !e7trose

CAvoid if patient on *6 theophylline

Followed by 4.;3.4mg7g7hr as infusion

CAvoid subse5uent bolus doses

To7i#ity

l ' $ardiac' $?*

Monitor levels if possible

/7ygen


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Maintain *a+2 2N.

,ypo)ia is mainly due to ( 7 X mismatch.

@agonists may parado)ically worsen

hypo)ia

Initially use oxyen to nebulise 82 aonists

/ral drugs as relie(ers


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+ral @2 agonists for intermittent airflow

obstruction.

+ral prednisolone for rescue therapy


167/204

Managing a#ute e'isodes

Bac to Arpit and his friends

Case11


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Arpit decides to help his mother with Diwali cleaning. ,e

starts coughing continuously soon after and his mother

rushes him to the clinic0

"hat 2uestions will you ask the mother3

interact !


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Case #ontd


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+n e)amination' Arpit has a respiratory rate of #& per

minute and a mild increase in accessory muscle activity.

,e appears comfortable and is able to tal in sentences.

Auscultation reveals a whee%e towards the end of

e)piration.

;ow will you grade Ar'its a#ute atta#k and

manage him3

Grading se(erity


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%#er a period of time-

helps to decide regarding need and choice of controller

medications for long term control

At a point in time -

helps to decide regarding the level of care and

drugs for an acute e)acerbation

Pulmonary s#ore inde7


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,#ore +es'iratory +ate "hee4ingF A##essory mus#le@K years K years ,ternomastoid a#ti(ity

4 I !4 I 24 ?one ?o apparent activity

3 !3#; 23!; Terminal Xuestionable increase

e)piration with

stethoscope

2 #&&4 !&;4 "ntire e)piration 1ncrease apparentwith stethoscope

! &4 ;4 During inspiration Ma)imal activity

and e)piration

without stethoscope

,#ore 4! Mild R1f no whee%ing due to minimal air e)change' score!#& Moderate

& *evere

'hose children whose score is -should be admitted to a pediatric ICU

;ome managementP, H 9mild grade:


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9 g :

*A @2 agonist9 2 - # actuations through MD1

spacer mas

6epeat every 3; - 24 mins for ma) ! times

1f response ill sustained CI # hrs' start 3stdose of

rescue steroid

Case11


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*anJana calls you in the middle of the night. *he isproceeding to the casualty once again. Vou rush in to

see her and find her to have a respiratory rate of #4 per

min. *he has suprasternal recessions and auscultation

reveals whee%e throughout e)piration.

Assess her se(erity and manage her

interact !

Pulmonary s#ore inde7


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,#ore +es'iratory +ate "hee4ingF A##essory mus#le

@K years K years ,ternomastoid a#ti(ity

4 I !4 I 24 ?one ?o apparent activity

3 !3#; 23!; Terminal Xuestionable increase

e)piration with

stethoscope

2 #&&4 !&;4 "ntire e)piration 1ncrease apparentwith stethoscope

! &4 ;4 During inspiration Ma)imal activity

and e)piration

without stethoscope

,#ore 4! Mild R1f no whee%ing due to minimal air e)change' score!#& Moderate

& *evere

'hose children whose score is -should be admitted to a pediatric ICU

* +oom 'lanP, D%K 9moderate:


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+2 *A @2 agonist

?ebulised 5 24 min ) !

or

MD1 spacer mas 2 puffs 5 2 min or so till & puffs reached. ive &

puffs lie this 5 24 min in the first hour.

or Cif inhaled therapy not available

Terbutaline single dose7Adrenaline 4.43mg7g sc 5 24 min ) !

$ommence 7 $ontinue rescue steroid

$ontinuous assessment for #-& hours

1f good responseCP* I!' decrease nebulisation to !-# hourly


177/204

*anJana does not respond to this treatment. +nehour later' her respiratory rate has gone up to ;4

per minute. Vou decide to admit her to the ward.

=Khat do we do ne)t8> ass your resident doctor

/utline your 'lan to him

interact !

"ard 'lan


178/204

$ontinue +)ygen' 1(7oral steroid

*tart 1( fluids

*A @2 nebuli%ation - hourly7 bac-to-bac

1pratropium neb 5 24 min ) ! and then 5 & hours

Monitor *a+2 and serum W

$B$' Y-6ay chest only to identify complications

Pulmonary score 5 3;-!4 minutes

Intensify if not $etter


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1( Magnesium *ulfate

$onsider blood gas studies if *a+2 I 2N

1( aminophylline bolus followed by continuous iv infusion Csip

loading dose if already on *6 theophylline

Terbutaline infusion if no response to aminophylline

$onsider transfer to P1$E facility


180/204

Vour resident doctor is new but means well. =Khatcomplications should 1 e)pect8> he ass and

=*ir7Madam' no antibiotics8 > he continues with a

bewildered loo.

"hat will you tea#h this young lad3

interact !

Com'li#ations


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Atelectasis

*econdary infection

Pneumothora)

Pneumomediastinum

*ubcutaneous emphysema

Therapy related

+ole of anti$ioti#s


182/204

Limited role $onsider only in those with

purulent secretions and

radiological evidence of pneumonia.

;acterial in#ections seldom trier asthma

!o not routinely use


183/204

Antibiotics Mucolytics

$ough suppressants

*edatives

$hest Physiotherapy

*team inhalation

Case


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!& hours later *anJana is showing signs of improvement. +n

your morning round' you find her sitting up comfortably sipping

her tea. *he says she slept well through the night. +n

e)amination she is mildly tachypnoeic and her whee%e is now

only in the terminal phase of respiration.

=$an 1 go home8> she ass

"hen will you de#ide to dis#harge her3

interact !

,te''ing down a#ute #are


185/204

Follow the principle =last in first out> Discontinue terbutaline 7aminophylline drip in 2#

hours

Discontinue ipratropium neb in 2# hours

6educe *A @2 agonist to 5 2-# hrly and then 5 #-

&hrly

6eplace iv steroid with oral steroid

!is#harge #riteria


186/204

Pulmonary score I !

*lept well at night

Feeding well

Appears comfortable.

?ot on any continuous infusions and receiving

less fre5uent 2 agonists Csay & hourly

Cases1 #ontd


187/204

"hat will you ad(ise Ar'it and ,an8ana when

they are ready to go home3

interact !

!is#harge 'lan


188/204

1nhaled *A @2 agonist MD1 spacer mas 5 #-&

hour till symptoms abate

$ontinue course of rescue steroid for !- days

CTapering not necessary

"ducate regarding home plan 7 long term strategy

Plan follow up visit within -3# days

6eview compliance' trigger elimination' controllerregime

Case1Meanwhile' 6aJu' a / year old with asthma is brought to the hospital in an


189/204

' J ' y g p

ambulance with o)ygen by mas.

,e istoo $reathless to s'eak' is sweatingand 5uite agitated. +n

e)amination his nails are duskyand on auscultation you hardly

perceive any air entry.

,e has shown no response to ! doses of nebuli%ed bronchodilator given

while he was rushed in with sirens blaring.

=ACT -A,TO $eg the 'arents1

interact !

Asthma+ed f lag signs


190/204

Enable to tal or cry

$yanosis

Feeble chest movements

Absent breath sounds

Fatigue or e)haustion

Agitated

Altered sensorium

+)ygen saturation I 2N

Treat or +efer3


191/204

+2 to be continued but monitor *a+2

1nJ adrenaline 7 terbutaline sc

1nhaled 2 agonist 1pratropium to be started

1nJ *teroids and iv fluid therapy

Arrange proper transport to 1$E

)o not send the patient withoutivin initial therapy!

'reat and refer.

IC) 'lan


192/204

$ontinue 7 initiate intensified ward plan

Blood gas studies

Possible intubation and mechanical ventilationwith etamine and mida%olam 7 fentanyl iv

infusion

Paralysis with vecuronium' if re5uired

To summari4e


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Asthma is an inflammatory illness

Diagnosis of asthma is clinical' and relies on history

All asthma does not whee%e

1n children I ?yrs' consider differential diagnosis before labelling

Many children outgrow their asthma

A family history of asthma 7 atopy increases ris of asthma

!iagnosis

To summari4e


194/204

Patient education is a very important part of asthma management

Drugs control' but do not cure asthma

$linical grading over time' decides long term management plan

1ntermittent asthma does not merit controllers

1nhaled steroids are mainstay of long term asthma management

Treatment should be stepped up or stepped down depending upon patient

response

.ong term management

To summari4e


195/204

rading at a point in time decides management

*A inhaled @2 agonists are used to manage acute e)acerbations

Fre5uent use of *A @2 agonists indicate poor control of asthma

Taing care of the home environment reduces e)acerbations of asthma

MD1 should always be used with spacer

A#ute management

!e(i#es


196/204

.adies and gentlemen

1t


197/204

+a8u Qhu$#handani

+! QhareA8it Ga8endragadkar

,ailesh Gu'ta

9.ate: Ritu JoraIndu Qhosla

!a'hin -ernandes

Con#e't and

#reation

>LH +e(ision Team


198/204

!r1 +a8u Qhu$#handani

!r1 A8it Ga8endragadkar

!r1 Jarinder ,ingh

!r1 ,ushil Qa$ra

!r1 G1+1 ,ethi

!r1 ,udarshan +eddy

National ATM Team >L

TE *EWEMA6A? President' 1AP U $hairperson


199/204

p

6+,1T $ A6AKALPresident-"lect' 1AP U $o-$hairperson

D""PAW E6A 1mm. Past President' 1AP

6AZ"*,KA6 DAVAL(ice President' 1AP U Kriting$ommittee

TA?MAV AMLAD1*ecretary eneral' 1AP U ?ational$onvener

*A1L"*, EPTA Treasurer' 1AP

VW AMD"WA6 Advisor

6P W,EB$,A?DA?1 Advisor

, PA6AM"*, Advisor

(A61?D"6 *1?, Advisor

*KAT1 V B,A(" Advisor

6 *"T,1 Advisor

National ATM Team >L

S NAGABHUSHANA ?ational $onvener


200/204

S NAGABHUSHANA ?ational $onvener

A BALA$,A?D6A? ?ational $oordinator

D (1ZAVA*"WA6A? Zoint ?ational $oordinator

** WAMAT, Zoint ?ational $oordinator

*E*,1L WEMA6 WAB6A *EB,A*1* 6+V

B * *,A6MA ZAD1*, $,1??APPA

P *ED"6*,A? 6"DDV P6A,ALAD WEMA6 A

6AZ T1LAW *E6"*, BABE

* *A?ZAV *+MA*,"WA6 A6

P6AD""P *1,A6" ?$ +K61*,A?WA6

APE6BA WEMA6 ,+*, D"(A6AZ ( 6A1$,E6WAL1 W1?WA6 ,+*, W ?AA6AZE

AETAM ,+*, 1?DE *A?Z""( W,+*LA

PALLAB $,ATT"6Z"" *,A6AD AA6W"DWA6

+e(ision done 9>LL=:


201/204

A Balachandran

, Paramesh

* ?agabhushana

D (iJayaseharan

6 *ethi

autam hosh

Z $hinnappa

W W hosh

L *ubramaniumMahesh Babu

* Balasubramanian

*o *hivbalan

* W Wabra

6aJu Whubchandani

*hishir Moda

(arinder *ingh

*ubhasis 6oy

Pallab $hatterJee

*uresh babu

T E *uumaran

? W *ubramanya

+e(ision done % >LLS


202/204

!r P1,1 ,uresh Ba$u !r Gautam Ghosh

$hairpersons'

1AP 6espiratory $hapter

!r Mahesh Ba$u !rQ Q Ghosh*ecretary'

1AP 6espiratory $hapter

!r1 ,1 Naga$hushana'

$oordinator' ATM '

1AP 6espiratory chapter

And team


203/204

Idea

T E *uumaran

*achidananda Wamat

*wati Bhave


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*pecial thans

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Asthma Training Module - 2013

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