1. 1. DR S RAGHU M.D., ASST PROF DEPT. T B & CD GUNTUR MEDICAL COLLEGE GUNTUR Dr s. raghu m.d., Associate professor Department of TB & CD R I M S medical college ONGOLE
2. 2. 100 m2 10,000 L blood pass every 24 hrs 10,000 L blood pass every 24 hrs 10,000 L air in & out every 24 hrs 10,000 L air in & out every 24 hrs 350 L of O2 delivered every day350 L of O2 delivered every day 100 m2 10,000 L blood pass every 24 hrs 10,000 L blood pass every 24 hrs 10,000 L air in & out every 24 hrs 10,000 L air in & out every 24 hrs 350 L of O2 delivered every day350 L of O2 delivered every day
3. 3. Definition: Asthma is a chronic inflammatory disorder of the airways in which many cells & cellular events play a role. The chronic inflammation is ass with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness & coughing, particularly at night or in the early morning. These episodes are usually ass with widespread but variable airflow obstruction within the lung that is often reversible either spontaneously or with treatment. GINA 2011
4. 4. Asthma is a Chronic Inflammatory Disease characterized by Airway Hyperresponsiveness to a variety of stimuli resulting in Bronchospasm which reverses, spontaneously or with treatment.
5. 5. 150 million people in the world(including many children) do not take breathing for granted WHO says- asthma is becoming most common chronic disease in children
6. 6. Asthma is a chronic disease most responsible for days off school. Night-time awakenings can affect a childs concentration in school next day Asthma significantly affects sports and recreational activities Missed days of school can affect a child's future career ( WHO estimates 14 million school days are lost every year due to Asthma across the globe )
7. 7. What happens in Asthma. Spasm & Swelling
8. 8. 20 million people with asthma 10-15% of children are sufferer Spread over rural & urban sector Not sparing affluent class
9. 9. Growing urbanisation & life style change Junk food 3 major pollens Parthenium, Casuarina and Eucalyptus have increased Increase in no. of industries and automobiles Smoking Ind J Ped 2002;69:309-12
10. 10. By 1 year 26% 1-5 years 51.4% > 5 years 22.3% Ind J Ped 2002;69:309-12 77% of all asthma begin in children less than 5 years
11. 11. Commonest chronic disease in children. More than 77% of the children present below the age of 5 years, The presentation closely mimics many conditions common in this age group The diagnostic modalities both spirometry and peak expiratory flow rate cannot be used in children below the age of 5 yrs
12. 12. Parents are proxy story tellers on behalf of the patients, and may exaggerate or undermine the nature of the disease. All this may lead to delayed diagnosis. Acceptance of inhalation therapy is another hurdle in the management of asthma
13. 13. Recurrent cough with or without breathlessness Nocturnal cough without viral respiratory tract infection Recurrent breathlessness
14. 14. Tightness of chest Seasonal variability Triggers Exercise induced exacerbation Family or personal history of asthma/atopy/allergy
15. 15. What are the Triggers? * Infections (Viral) *Strongsmells,perfumes deodorants * Pets * House dust * Pollen * Tobacco smoke * Pollution * Climate (Cold days Humid days) * Exercise * Emotion * Food Additives Colouring agents preservatives * Drugs
16. 16. Pollution
17. 17. Allergens Irritants Pollution
18. 18. Normal individual Allergen stimulates production of IgE, in equal no. to allergen. Allergen destroyed Allergic individual Allergen stimulates excess production of IgE. Some Allergens get destroyed. Rest cause allergic reaction.
19. 19. Associated conditions Eczema Rhinitis Hay fever Relief with bronchodilators with or without oral steroids Weight & Height
20. 20. Afebrile episodes Personal atopy
21. 21. step 1 Good Clinical History step 2 Careful Physical Examination step 3 Investigations
22. 22. Spirometry Spirometry can be performed when diagnosis is in doubt as well as for periodic monitoring of asthma. Disadvantages Cannot be done in children below the age of 5 yrs Technical expertise required
23. 23. Measurement of Peak expiratory flow rate (PEFR) with a peak flow meter The peak expiratory flow rate is the easiest to perform in children above the age of 5 yrs. It can help the patient assess the presence of wheezing and can help in self- monitoring.
24. 24. It is highly suggestive of asthma if there is: 20% increase in PEFR after inhaled short-acting beta2 agonist 20% decrease in PEFR after exercise Diurnal variation 20% in children not on bronchodilator
25. 25. Normally a diurnal variation 3 years (most likely asthma) Aspiration Syndromes Bronchiolitis Asthma Bronchiolitis Transient Wheezing of Childhood (TWC) TWC Congenital Heart Disease Early onset asthma foreign body aspiration Congenital Malformations of Respiratory Tract Foreign body aspiration congenital heart disease Congenital Heart Disease Infection like TB, etc
26. 28. Stridor/Noisy breathing Viral mediated hyper-reactive airways Tuberculosis and Pertussis Foreign body Tropical eosinophilia
27. 29. Presence of these can make control of asthma difficult and hence they should be identified and treated: Allergic Rhinitis Adenoidal Hypertrophy Gastro Oesophageal Reflux Disease (GORD or GERD)
28. 30. All Asthma Does Not Wheeze Recurrent cough Tightness of chest
29. 31. Firstly, and most importantly, it is necessary to inform about the chronic nature of asthma, including the fact of acute exacerbations in between episodes Emphasize on the point that this disease is controllable but not curable.
30. 32. Also, emphasize on the fact that inhalation therapy is the gold standard treatment for asthma. At the same time, the myths and the misconceptions about inhalation therapy should be resolved. Discuss the selected regime and address the concerns regarding steroid use.
31. 33. Discuss the usage and maintenance of the inhaler device. Also advise on bringing the device along for each follow-up. Emphasize on the need for a regular follow-up. Explain the need for adherence with the treatment .
32. 34. Advise regarding avoidance of triggers. Note that diet has a limited role in the causation of asthma. Patients / parents should be advised to maintain a diary to record the significant events and carry it with them every time they go for a follow-up.
33. 35. By significant events, we mean daytime cough, night time cough, reliever medication use, emergency visits, etc. Educate regarding the management of acute exacerbations at home prior to visiting a doctor
34. 36. Viral infections Smoke - cigarettes, kitchen, etc. Fungi, mold, spores Pets Food items known to cause asthma Aspirin/NSAID sensitivity Beta-blocker-induced bronchospasm Obesity
35. 37. Humidity Weather Industrial and automobile pollution
36. 38. Oral Inhaled Parenteral Tablets Syrup Metered dose inhaler (MDI) Dry powder inhaler (DPI) Injections Which is the best route for anti-asthmatic drugs??? Nebulizers
37. 39. WHY INHALATION THERAPY? Small doses of Drug High Local Concentration Low Systemic Concentration Efficacy Safty
38. 40. Less Drug Without Side effects Straight into the Lungs Why Inhaled Therapy ? Salbutamol 4 mg Tabs 40 Puffs of salbutamol Inh
39. 41. The health-care provider should evaluate inhaler technique at each visit.
40. 42. Symptoms Nocturnal symptoms FEV1/PEF Intermittent 1 time a week but < 1 time a day >2 times a month 80% predicted Variability 20 - 30% Moderate persistent Daily attacks affect activity >1 time a week 60 - 80% predicted Variability > 30% Severe persistent Continuous limited physical activity Frequent 60% predicted Variability > 30%
41. 43. Characteristic Controlled Partly controlled (Any present in any week) Uncontrolled Daytime symptoms None (2 or less / week) More than twice / week 3 or more features of partly controlled asthma present in any week Limitations of activities None Any Nocturnal symptoms / awakening None Any Need for rescue / reliever treatment None (2 or less / week) More than twice / week Lung function (PEF or FEV1) Normal < 80% predicted or personal best (if known) on any day Exacerbation None One or more / year 1 in any week
42. 44. A dose response study using budesonide in children with moderate and severe persistent asthma indicated that 83% achieved control of exercise induced asthma with a dose of 400 mcg/day . There is little risk of systemic effects if inhaled corticosteroids are used in doses of less than 400 g/day (beclomethasone equivalent). von Berg A, Engelstatter R, Minic P, Sreckovic M, Garcia MLG, Latos L et al.
43. 45. Following commencement of therapy, the dose of inhaled corticosteroid should be titrated according to clinical response, aiming for the minimum dose that will provide continuing control of asthma symptoms. While the majority of studies of inhaled corticosteroids in children have employed twice daily dosing, studies with ciclesonide have demonstrated that that once daily dosing is effective .
44. 46. The dose of inhaled corticosteroid delivered to the lungs will depend on many factors including the delivery device, the age of the child, individual variation in inhaler technique, and adherence. Pedersen S, Engelstatter R, Weber H-J, Hirsch S, Barkai L, Eneryk A et al.
45. 47. Majority of studies have used 2mg/kg oral prednisolone , (maximum 60 mg) given initially and subsequently daily doses of 1mg/kg if required.
46. 48. Duration of therapy will generally be up to 3 days (a 5 day course has not been shown to confer any advantage over a 3 day course in non hospitalized children , but in patients with severe persistent asthma a more prolonged course may occasionally be needed with tapering of the dose to prevent asthma relapse.
47. 49. Although a recent comparison of oral dexamethasone(0.6mg/kg) with oral prednisololone (2mg/kg) demonstrated that a shorter course of dexamethasone provided equal benefit and was better tolerated , concerns were raised about the greater potential for adrenal suppression with dexamethasone related to its longer half-life.
48. 50. While there appears to be no definite advantage of parenteral over oral corticosteroids , intravenous corticosteroids (methylprednisolone in an initial dose of 2mg/kg, up to 60mg, subsequent doses 1mg/kg every 6 hours on day 1, then every 12 hours on day 2, then daily) will be needed if the child is extremely ill, unconscious, or cannot tolerate oral medication. Hydrocortisone 8-10mg/kg (max 300mg) initially then 4-5mg/kg/dose can be used as an alternative parenteral corticosteroid.
49. 51. Short bursts of oral corticosteroids (3 to 10 days) are administered to children with acute asthma exacerbations. The initial starting dose is 1 to 2 mg/kg/day of prednisone followed by 1 mg/kg/day over the next 2 to 5 days. (nelson text book of paeds)
50. 52. controlled partly controlled uncontrolled exacerbation LEVEL OF CONTROL maintain and find lowest controlling step consider stepping up to gain control step up until controlled treat as exacerbation TREATMENT OF ACTION TREATMENT STEPS REDUCE INCREASE STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 REDUCEINCREASE
51. 53. Infants Nebulizer Children < 4 years Nebulizer/ MDI with spacer with facemask 4 -6year MDI with Spacer >6 years DPI >12years MDI Acute episodes Nebulizer
52. 54. The prescribed treatment can be considered effective when: The child is normal and asymptomatic He/she is not awakened by symptoms of asthma He/she can go to school and have a normal lifestyle He/she can play with the peers without getting any symptoms
53. 55. Exacerbations of asthma (asthma attacks) are episodes of a progressive increase in shortness of breath, cough, wheezing or chest tightness or a combination of these symptoms.
54. 56. The economic costs of asthma are estimated to be more than those of HIV/AIDS and tuberculosis combined.
55. 57. Oxygen is given if the patient is hypoxemic (achieve O2 saturation of 92%- 95%). Inhaled rapid-acting 2 -agonists such as salbutamol or levosalbutamol in adequate doses are essential First hour 2-4 puffs Every 20 mts Mild 2-4 puffs 3-4 hrs moderate 6-10 puffs 1-2 hrs
56. 58. Oral glucocorticosteroids 0.51 mg of prednisolone/kg or equivalent introduced early in the course of a moderate or severe attack help to reverse the inflammation and speed recovery
57. 59. Methylxanthines are not recommended routinely. However, theophylline can be used if inhaled 2- agonists are not available. If the patient is already taking theophylline on a daily basis, serum concentration should be measured before adding short- acting theophylline.
58. 60. Sedatives (strictly avoid). Mucolytic drugs (may worsen cough). Chest physical therapy/physiotherapy (may increase patient discomfort).
59. 61. Hydration with large volumes of fluid in case of adults and older children (may be necessary for younger children and infants). Antibiotics (do not treat attacks, but are indicated for patients who also have pneumonia or bacterial infection such as sinusitis).
60. 62. A subcutaneous or intramuscular injection of epinephrine (adrenaline) may be indicated for acute treatment of anaphylaxis and angio-oedema, but is not routinely indicated during asthma attacks. Intravenous magnesium sulphate has not been well-studied in young children and is usually used when all the above fails.
61. 63. Asthma is the most common chronic disorder affecting children 5%-10% Up to 2-3 children in each classroom may be affected by asthma It is a serious disease and can be fatal
62. 64. A majority of children affected by asthma are undiagnosed, misdiagnosed or unlabeled Over 50% of children remain uncontrolled and hence can affect school performance
63. 65. Traditional treatment Occasional RelieversIdeal treatment Regular Controllers Steroid
64. 66. Minimal (ideally no) chronic symptoms Minimal (ideally no) need for as needed use of relievers No emergency visits (Near) normal PEF Minimal (infrequent) exacerbations PEF circadian variation of less than 20 percent No limitations on activities, including exercise Minimal (or no) adverse effects from medicine
65. 67. Routes of administration of anti-asthma drugs Advantages of inhalation therapy over oral route Drug therapy for asthma Differences between relievers and controllers
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