self management of asthma
TRANSCRIPT
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Dr. Md. Khairul Hassan JessyAssociate Professor
Respiratory Medicine
NIDCH,Mohakhali,Dhaka
Self Management of Asthma
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Introduction
To define the self management plan
To highlight the importance
To discuss the detailed procedure
Conclusion
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In the last few years there have been
remarkable progress and
outstanding improvement
in the management of Asthma
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But sadly, many patients of
developing countries are getting
unplanned
&
unscientific management
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With
education, caution & medication most cases of
asthma can be effectively managed
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History
Asthma was first recognized in
ancient Egypt &
treatment was
inhalation of frankincense
Source : Wikipedia
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History…..
It was first recognized as a specific respiratory problem &
named by
Hippocrates
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History…..
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History…
The most recent advancement is
Combination of ICS & LABA with
Adjustable Maintenance Dose (AMD)or
Single Maintenance And Reliever Therapy (SMART)
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Asthma is a
chronic inflammatory disease affecting
the airways with typical symptoms of
cough, wheezing, breathlessness
& chest tightness
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Unified definition
Asthma is a chronic inflammatory disorder causing hyper-responsiveness of the airways to certain
stimuli resulting in recurrent variable airflow limitation at least partially reversible with treatment or spontaneously
manifested as shortness of breath, wheeze, cough and
chest tightness
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It is not a curable diseaseBut to a large extent
It is
controllable like Diabetes & Hypertension
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It is not a curable diseaseBut to a large extent
It is
controllable like Diabetes & Hypertension
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Use of
anti- inflammatory preventive drugsfor 2-5 years may lead to
Complete Remission in60 – 80 % of Childhood asthma
20 – 30 % of Adult asthma
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But many serious episodes can
be avoided by
proper education and
care at home
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Pharmacological management& Medicines of Asthma
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Pharmacological management of Asthma…
The mainstay of asthma therapy is the
use of inhaled drugs
the advantages of this method are that drugs are
delivered direct to the airways and
avoid passage to the liver
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Pharmacological management of Asthma…
thus lower doses are necessary and systemic
unwanted effect are minimized
The drugs used in asthma should be given in a
stepwise fashion according to the severity and
frequency of the attacks
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Medicines of Asthma:
Medicine used to treat asthma are basically three
types
A) Relievers
B) Preventers
C) Protectors
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A) Relievers
These medicines relax smooth muscles that
have tightened around the airways.
They relieve asthma symptoms.
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A) Relievers (Bronchodilators)…
1. Short acting β2-agonists (SABA)
SalbutamolTerbutaline
2. Short acting Xanthenes' derivatives
TheophyllineAminophylline
3. Anticholinergics Ipratropium bromideOxitropium bromideTiotropium
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B) ProtectorsThese medicines are long acting bronchodilator
medicines which prevent the recurrence of attacks
particularly nocturnal symptoms.
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B) Protectors (Symptom controllers)
1) Long acting β2 agonist (LABA)
Salmeterol Formoterol
2) Long acting Xanthene derivatives
TheophyllineAminophylline
3) Sustained released Salbutamol
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C) Preventers
medicines reduce or reverse the swelling in the airways
These medicines also prevent the initiation of inflammation after exposure to trigger factors
Thereby they prevent asthma episodes
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C) Preventers (Anti-inflammatory medicines)
I)Corticosteroids •Inhaled•Oral
II) Cromones •Nedocromil sodium•Sodium Cromoglycate
III) Xanthene derivatives •Aminophylline and •Theophylline
IV) Antileukotrienes •CysLT-1 receptor inhibitor: •Montelukast and •Zafirlukast •Enzyme inhibitor: Zileuton
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Newer and Disease modifying Drugs
Newer Drugs
Omalizumab (Xoliar)
Magnesium Sulfate
Frusemide
Ciclesonide
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Newer and Disease modifying Drugs…
Disease modifying agents
Methotraxte,
Cyclosporin-A &
Gold-salts
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OMALIZUMAB (XOLIAR) Considerations for IgE blocker Therapy
Monoclonal anti-IgE ab preparation
Inhibit binding of IgE to mast cell – does not
provoke mast cell degranulation
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OMALIZUMAB (XOLIAR) Considerations for IgE blocker Therapy…
Patient at least 12 years of age Evidence of reversible disease (such as 12% or
greater improvement in FEV1 with at least a 200-ml increase
or 20% or greater improvement in PEF) IgE level ≥ 30 IU/ml
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OMALIZUMAB (XOLIAR) Considerations for IgE blocker Therapy…
Systemic corticosteroids or high-dose inhaled
corticosteroids required to maintain adequate control
As directly observable therapy in patients who are not
adherent to prescribed therapy
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OMALIZUMAB (XOLIAR) Considerations for IgE blocker Therapy…
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An overview of asthma triggers
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Asthma Triggers…
A trigger is anything that irritates the airways
and causes the symptoms of asthma
Normal healthy person is not bothered by those
triggers
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Asthma Triggers…
Everyone's asthma is different and you may have
several triggers
An important aspect of controlling your asthma is
avoiding your triggers
It may be impossible to avoid all of your triggers
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Asthma Triggers…
but once you've identified them
there are things you can do to help you to reduce
unnecessary symptoms and
better control of your asthma
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Unhealthy indoor environment for asthma patient
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Asthma Triggers…
Why To identify asthma triggers?To prevent some asthma attacks
To reduce the frequency and severity of some attacks
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The patient is trying to control his asthma without removing
trigger factor
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Asthma Triggers…
Detection of trigger by monitoring the lung function
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To control asthma, PEP (Positive Expiratory Pressure) is so important that if they are
educated properly, then-73% of hospital admission from acute attack
of asthma can be reduced and80% of death from asthma can be prevented
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Effortless easy breathing- is our goal24 hours a day
30 days a month
12 months a year
-with an intention for full remission
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Non- Pharmacological
- Education- CautionPharmacological
- Medications used in management
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We should educate our people
in their own languageBased on
- our scientific knowledge- less scientific terminology- less comprehensive patho-physiology
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GINA aimsGINA guidelines
published
Implementation GINA guidelines
How are we doing?
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Patients? Physicians?
Healthcare system?
Asthma control
Who is responsible for asthma control?
Researchers?
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41.1
14.5
35.4
Asia PacificEuropeUSA
% of patients100
0
80
60
20
40
Rabe et al. Eur Respir J 2000;www.asthmainamerica.com;
Lai et al. J Allergy Clin Immunol 2003
Patients with persistent asthma receiving controller therapy
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Asthma control in practice was poor
Doctors didn't follow
guidelines,
underestimate severity and
may confuse severity with control
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Patients underestimate
the severity of their own disease
Guidelines were complex and can be difficult
to follow
Only 5% of patients achieved GINA-defined
control
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Control of asthma means, patient-
is almost asymtomatic
can perform normal daily activities
requires reliever bronchodilator(sulbutamol
inhalation)<1 time a day
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is free of nocturnal symptoms; if occurs , less
than two times per month
has PEFR reading >80% of personal best result
has <10% diurnal variability in Peak Flow Chart,
if available
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has no history of emergency visit to doctors
or hospitals
has no or minimal side effects of medication
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If we educate our patient properly
Then patient will cautiously avoid allergens
to control bronchial asthma
They will use their medications with an
intension to get remission
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Includes –
Home Management
- of stable asthma
Emergency Management
-Loss of control of asthma
-Difficult to treat asthma
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Asthma is a chronic disease and it should be
managed at home, except severe acute asthma
If home management plan is applied intelligently
and skillfully most asthmatics can lead a
symptom-free near-normal life
They may avoid hospitalization thereby
decreasing the financial expenditure significantly
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There are two types of plans without self-management plan
with guided self-management plan
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The patient is educated
Appropriate precautionary measures
are advised
“Step care management’’ is employed
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The prescription is quite inflexible whatever be the condition
patient will not increase the drugs except β 2 agonist ( salbutamol ) inhaler
Salbutamol inhaler may be taken as per need upto 4-6 times / day
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Development of a guide on the basis of best Peak Flow is known as guided self management plan. Patient will measure his lung function with the help of a peak flow meter and on the basis of best peak flow results, patients will modify their treatment.
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Peak Flow Meter
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lead a symptom free near normal life
avoid many serious episodes of acute
asthma &
Chances of mortality and morbidity is
reduced considerably
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Time consuming
More laborious
Needs patient compliance
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Flow meters are devices to measure
the strength of airways (force of
inspiration and expiration)
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Types of flow meters are
Peak expiratory flow meter ( peak flow
meter)
Incentive Spirometer
Peak inspiratory flow meter ( PIF )
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The measurement of peak expiratory
flow was pioneered by Martin Wright
who produced the first meter to
measure lung function
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The original design of instrument was
introduced in the late 1950s
and the subsequent development of a more
portable, lower cost version is the "Mini-
Wright" peak flow meter
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Who Should Use a Peak Flow Meter?
People with moderate-to-severe asthma should have a
peak flow meter at home.
Even Peak flow meters are very helpful if a child have
moderate to severe asthma and require daily asthma
medications.
Most children ages 6 and up may be able to use a
peak flow meter.
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PEF(Peak expiratory flow):
It is the highest flow one can achieve
during forceful expiration
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The peak flow meter measures how fast air comes out of
the lungs when a person exhale forcefully after inhaling fully
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Inexpensive, portable & handy device.Only measures the amount of airflow out of the large
airways of the lungs.Small airways (which also occur with asthma) will not
be detected by a peak flow meter.
Depends on a patient's sex, age and height.
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Move the marker to the bottom of the numbered scale.
Stand up if you're able.
Take a deep breath, filling your lungs completely.
Place your lips tightly around the mouthpiece.
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Blow as hard and as fast as you can with a single breath.
Note the final position of the marker. This is your peak flow rate.
Follow the steps above then blow into the peak
flow meter two more times.
Best of 3 blows is recorded.
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To recognize early changes that may be signs of
worsening asthma and thus preventing asthma attack.
During an asthma attack, the muscles in the airways
tighten and cause the airways to narrow.
The peak flow meter alerts you to the tightening of
the airways often hours or even days before the
development of asthma symptoms.
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By following the steps in asthma action plan,
patient may be able to
stop the narrowing of the airways
quickly and
avoid a severe asthma emergency
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Mainly Used to find out early asthma attack (long before the
onset of symptoms) & by doubling the medicine a
serious episode can be avoided Used as a short term monitoring tool at
Doctor’s chamber & emergency room during exacerbations
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Long term monitoring of asthma at patient’s home
by maintaining peak flow chart essential for constructing self
management plan
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Can also be used to see whether the management plan is working or not to decide when to add or stop medicine to decide when the patient seeks emergency care to identify triggers
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By using own PEF with his/her asthma action
plan, he/she will know when to take his/her
rescue asthma inhaler or other asthma
medicine.
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Diurnal variability = (highest PEF – lowest PEF)X100 highest PEF
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How to take care of Peak Flow Meter?
Most peak flow meters require weekly cleaning with warm water and a mild detergent.
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PEF varies throughout the day.
In a person who does not have asthma, it may
vary between 10% and 15%.
In a person who has poorly controlled asthma,
it may vary more than 20%.
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Peak Flow Chart
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Peak Flow Chart
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The highest peak flow measurement of a patient
achieved over a two week period when patient’s
asthma is totally/ well controlled
“Self management plan” needs to be constructed
depending on his own personal best peak flow value
A person's personal best is his or her highest peak flow.
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Determine by taking readings over 2 weeks
when the asthma is under control.
Should be recorded at least twice daily.
Best is usually reached in the evening.
Never measured during an asthma attack.
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Patient will-Record his personal best peak flow result in the prescribed peak flow diary or chart3 zones will be demarcated in the diaryTake peak flow reading every morning on waking up and night at bedtimePeak flow readings should be taken at the same time each dayThey will also write down if they were exposed to any trigger factor’s initiating an attack.
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Patient will- Peak expiratory flow is lowest in the early
morning and highest in the afternoon. If patient wants to take the test only one time
during the day, they should take it first in the morning, before using a bronchodilator medicine.
note how many times they took extra reliever asthma medicine to stop their symptoms every day
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( 3 basic steps )( 3 basic steps )Step 1Step 1
Patient will measure the lung function with peak flow meter & maintain a
peak flow chart
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( 3 basic steps )Step 2
With this chart - patient’s personal best peak flow result is
determinedOn that basis readings are recorded in a
chart with 3 color zones :Green,Yellow, Red
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Peak Flow Chart
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( 3 basic steps )Step 3
Physician will develop one prescription for each zone
Patient is educated to modify drugs up to a certain limit
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Peak Flow Zone System
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3 traffic light colors are used to measure the control of asthma
Green
Yellow
Red
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Green zone indicates
well controlled asthma
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Green zone ( safety zone ) peak flow 100 - 80 % of personal best
no/minimal symptoms maintenance therapy continuesinhaled β 2 agonists may be used in some specific
situations
( before exercise / mild symptoms)
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Yellow zone ( zone of alert )
- PEF is < 80 –> 60 % of personal best
o Asthma symptoms –
cough ( nocturnal )
breathlessness
wheezing may be present
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Yellow zone ( zone of alert )…suggestive of – Acute exacerbation or gradual deterioration of
severity of asthma Consultation with physician is needed . Patient will double his preventer drug and take one or
two oral protector drugs.
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Red zone ( zone of emergency ) This signals a medical alert
o PEF is < 60 % of personal bestoAsthma symptoms are present at rest and
interferes activityo β 2 agonist should be taken immediatelyo patient will start rescue oral steroid &o should contact the physician ( may need
hospitalization )
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Red Zone means
Along with prescription of yellow Zone
patient will start rescue oral steroid and
should contact a physician immediately
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Scenario 1: Mr. X , 45 years - known case of bronchial
Asthma & Allergic Rhinitis Personal best peak flow result =500L/min Present PEFR = 420 l/min
Questions: 1.PEF Zone? 2.What treatment to be given?
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Ans. 1. Green Zone 2.Rx
Inhaler Fluticasone/Salmaterol (125/25)2 puffs 12 hourly (contd) (gargle after use)
Inhaler Salbutamol 2 puffs SOS
Tab. Montelukast 10 mg 0+0+1(contd)
Tab. Fexofenadine 120/Rupatidine 100+0+1 SOS
Fluticasone nasal spray2 puffs once daily in the morning (sos)
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Scenario 2:Mr. X , 45 years - known case of bronchial Asthma & Allergic Rhinitis
Personal best peak flow result=500L/minPresent PEFR = 350 l/min
Questions: 1.PEF Zone? 2.What treatment to be given?
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Ans. 1.Yellow Zone 2.Rx:
Inhaler Fluticasone/Salmaterol(250/25)2 puffs 12 hourly (contd)(gargle after use)
Inhaler Salbutamol 2 puffs sos
Tab. Montelukast 10 mg 0+0+1(contd)
Tab. Fexofenadine 120/Rupatidine 10 0+0+1 sosTheophylline S.R.(200 mg)
0+0+1 (contd)Fluticasone nasal spray 2 puffs once daily in the morning (contd)
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Scenario 3:
Mr. X , 45 years - known case of bronchial
Asthma & Allergic Rhinitis
Personal best peak flow result = 500 L/min
Present PEFR = 150 l/min
Questions:
1.PEF Zone?
2.What treatment to be given?
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Ans. 1.Red Zone
2.RxTab. Prednisolone (20 mg)
2+0+0 (after meal) 7 days
Tab. Esomoprazole (20 mg)
1+0+1
+treatment of yellow zone(to contact physician immediately)
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Asthma is not a curable disease But total/well control is possible in almost all
cases by
oproper Educationotaking Caution ( regarding
environmental control )&
oNeed for Medication.
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Asthma is a chronic disease and it
should be managed at home except
severe acute asthma
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THANK THANK YOU !YOU !