Management of asthma and copd
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Transcript of Management of asthma and copd
A chronic inflammatory disorder of the airway
Infiltration of mast cells, eosinophils and lymphocytes
Airway hyperresponsiveness Recurrent episodes of wheezing,
coughing and shortness of breath Widespread, variable and often
reversible airflow limitation
Predisposing Factors Atopy
Causal Factors Indoor Allergens
Domestic mites Animal Allergens Cockroach Allergens Fungi
Outdoor Allergens Pollens Fungi
Occupational Sensitizers
Contributing Factors
Respiratory infections
Small size at birth Diet Air pollution
– Outdoor pollutants– Indoor pollutants
Smoking– Passive Smoking– Active Smoking
Genetic factors
Environmental factors
Atopic sensitization
Structural changes
Mucosal inflammation
Phenotype
1. Extrinsic or allergic: History of `atopy` in childhood Family history of allergies Positive skin test Raised IgE level Below 30 years of age Less prone to status asthmaticus
2. Intrinsic or Idiosyncratic: No family history of allergy Negative skin test No rise in IgE level Middle age onset Prone to status asthmaticus
STEP 4Severe
Persistent
STEP 3Moderate Persistent
STEP 2Mild
Persistent
STEP 1Intermitte
nt
The presence of one of the features of severity is sufficient to place a patient in that category.
Global Initiative for Asthma (GINA) WHO/NHLBI, 2002
SymptomsNighttimeSymptoms
PEF
CLASSIFY SEVERITYClinical Features Before Treatment
ContinuousLimited physical activityDailyUse 2-agonist dailyAttacks affect activity>1 time a week but <1 time a day
< 1 time a weekAsymptomatic and normal PEF between attacks
Frequent
>1 time week
>2 times a month
<2 times a month
<60% predictedVariability >30%>60%-<80% predictedVariability >30%>80% predictedVariability 20-30%>80% predictedVariability <20%
GINA Guideline clearly states that THERE IS NO CURE FOR ASTHMA, But appropriate management most often leading to CONTROL of asthma
Relievers Preventers Peak Flow meter Patient education
- Rescue medications- Quick relief of symptoms- Used during acute attacks- Action lasts 4-6 hrs
Short acting 2 agonistsSalbutamolLevosalbutamol
Anti-cholinergicsIpratropium bromide
XanthinesTheophylline
Adrenaline injections
Selective 2 agonist
ATP
cAMP
Theophyline
5’-AMP
Relaxation
Ach
Ipratopium
Vagus nerve
- Prevent future attacks- Long term control of asthma- Prevent airway remodelling
Corticosteroids Anti-leukotrienesPrednisolone, Betamethasone Montelukast,
ZafirlukastBeclomethasone, Budesonide
Fluticasone Xanthines
Theophylline SR
Long acting 2 agonists Mast cell stabilisersBambuterol, Salmeterol Sodium cromoglycateFormoterol
COMBINATIONS
Salmeterol/FluticasoneFormoterol/Budesonide
Salbutamol/Beclomethasone
SALBUTAMOL INHALER100 mcg:1 or 2 puffs as necessary
LEVOSALBUTAMOL INHALER 50 mcg :1 or 2 puffs as necessary
Formoterol ( fast relief and sustained relief ) +
Budesonide ( twice or even once daily use )
Dose: 1- 4 puffs ( OD/BD )
Another combination
Salmeterol + Fluticasone
Metered dose inhalers
Dry powder inhalers
(Rotahaler)
Spacers / Holding
chambers
SpacerDry PowderInhaler
Metered Dose inhaler
Step I: When symptoms are less than once daily - occasional inhalation of a short acting Beta-2 agonist – salbutmol, terbutaline. If used more than once daily – step II (Mild episodic asthma)
Step II: Regular inhalation of low-dose steroids. Alternatively, cromoglycates. Beta-2 agonist as and whenever required (Mild chronic asthma)
Step III: Inhalation of high dose of steroids (800 mcg) + Beta-2 agonist. Sustained release theophylline may be added. LT inhibitors may be tried instead of steroids (Moderate asthma with frequent exacerbations) - spacers
Step IV: Higher dose of steroid (800 to 200 mcg) + regular beta-2 agonist (long acting salmeterol)
Additional treatment with oral drugs – LT antagonist or SR theophylline or oral beat-2 agonist
allergenavoidance
indicated when possible
allergenavoidance
indicated when possible
pharmacotherapysafety
effectivenesseasy to be administered
pharmacotherapysafety
effectivenesseasy to be administered
immunotherapyeffectiveness
specialist prescription may alter the natural course of the disease
immunotherapyeffectiveness
specialist prescription may alter the natural course of the disease
patient'seducation
always indicated
patient'seducation
always indicated
ARAR
Older siblings:Many infections
[TH1 stimuli]
TH1No allergies
Still TH2Allergies
Only child:Few infections
AllergenExposure
Source: Busse WW, Lemanske RF. N Engl J Med 2001.
Birth:TH2
Patients diagnosed with allergic asthma
Patients diagnosed with allergies such as hay fever
Patients diagnosed with sinusitis that predisposes them to asthma
Patients diagnosed with insect sting allergy
COPD is characterized by airflow limitation caused by chronic bronchitis or emphysema often associated with long term tobacco smoking
This is usually a slowly progressive and largely irreversible process
Consists of increased resistance to airflow, loss of elastic recoil, decreased expiratory flow rate, and overinflation of the lung.
COPD is clinically defined by a low FEV1 value that fails to respond acutely to bronchodilators, a characteristic that differentiates it from asthma.
Chronic Bronchitis is characterized by Chronic inflammation and excess mucus
production Presence of chronic productive cough
Emphysema is characterized by Damage to the small, sac-like units of the lung
that deliver oxygen into the lung and remove the carbon dioxide
Chronic cough
*Source: Braman, S. Update on the ATS Guidelines for COPD. Medscape Pulmonary Medicine. 2005;9(1):1.
Normal versus Diseased Bronchi
Smoking Air pollution genetic (hereditary) risk
Night time waking with breathlessness or wheeze is common in asthma and uncommon in COPD.
COPD is rare before the age of 35 whilst asthma is common in under-35.
Classification of COPD Severity by Spirometry
Stage I: Mild FEV1/FVC < 0.70 FEV1 > 80% predicted
Stage II: Moderate FEV1/FVC < 0.70 50% < FEV1 < 80% predicted
Stage III: Severe FEV1/FVC < 0.70 30% < FEV1 < 50% predicted
Stage IV: Very Severe FEV1/FVC < 0.70 FEV1 < 30% predicted or
FEV1 < 50% predicted plus chronic respiratory failure
Physical examinationSigns of heavy smokers Observe for clubbing Distended neck vein on expiration The presence of barrel chest Observe for abdominal breathing The use of pursed lips breathing and
chest movement Auscultate the chest& listen for musical
wheezes characteristics of chronic bronchitis
Symptoms Physical examination Sample of sputum Chest x-ray High-resolution CT (HRCT scan) Pulmonary function test (spirometery) Arterial blood gases test Pulse oximeter
Give antibiotics to treat infection
Give bronchodilators to relieve bronchospasm, reduce airway obstruction, mucosal edema and liquefy secretions.
Chest physiotherapy and postural drainage to improve pulmonary ventilation.
Proper hydration helps to cough up secretions or tracheal suctioning when the patient is unable to cough.
Steroid therapy if the patient fails to respond to more conservative treatment.
Stop smoking
Oxygenation with low concentration during the acute episodes
In asthma adrenaline ( epinephrine) SC if the bronchospasm not relieved.
Aminophylins IV if the above treatment does not help.
IV corticosteroids for patients with chronic asthma or frequent attack.
Sedative or tranquilizers to calm the patient.
Increase fluids intake to correct loss of diaphoresis and inaccessible loss of hyperventilation.
Intubations and mechanical ventilation if there is respiratory failure.
Oxygen therapy Used as long-term continuous therapy, during
exercise, or to relieve acute dyspnea Improves survival in COPD patients with severe
hypoxemia (partial pressure of oxygen [pO2] < 55 mm Hg or oxygen saturation [sO2] <88%) (Strength of Recommendation [SOR]: A) When used for >15 hours daily
Does not improve survival in patients with moderate hypoxemia or desaturation at nightCranston, 2008
GOLD, 2009
Annual flu vaccine Reduces risk of flu and its complications
Pneumonia vaccine Reduces risk of common cause of pneumonia
lobal Initiative for Chronic
bstructive
ung
isease
lobal Initiative for Chronic
bstructive
ung
isease
G
OLD
G
OLD
November 19, 2006World COPD Day, Kyoto Japan
Definition, Classification Burden of COPD Risk factors Pathogenesis, pathology,
pathophysiology Management Practical Considerations
Definition, Classification Burden of COPD Risk factors Pathogenesis, pathology,
pathophysiology Management Practical ConsiderationsRevised 2006
THANK YOU