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Training Module

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Title: Training Module


1
Training Module
2
Why are we here today?
  • Cough, breathlessness and wheezing are common
    symptoms with which patients (adults as well as
    children) present to physicians
  • The list of differential diagnosis for these
    symptoms includes pulmonary diseases (like COPD,
    asthma, bronchiectasis, tuberculosis and lung
    cancer) and cardiac diseases (like ischemic heart
    disease, left ventricular failure and valvular
    heart disease)
  • The module is aimed at giving an overview of the
    two most important etiological entities (asthma
    and COPD) for these symptoms as well as their
    management (diagnosis based on clinical
    features/investigations and treatment based on
    severity)

3
Objectives
  • At the end of training, the general practitioner
    (GP) should be able to
  • Evaluate a patient presenting with symptoms of
    cough, breathlessness and wheezing as well as
    conduct relevant examination in order to diagnose
    asthma/COPD clinically
  • Undertake and interpret relevant investigations
    peak expiratory flow (PEF) measurement,
    spirometry and chest x-ray (if available) to
    confirm the presence of airflow obstruction and
    to rule out other diagnoses (TB,bronchiectasis
    etc.)

4
Objectives
  • Differentiate the two main causes of airflow
    obstruction (asthma and COPD)
  • Clinically assess the severity of airflow
    obstruction
  • Recognize cases (of asthma and COPD) in whom
    referral to specialist or higher centre is
    required
  • Manage and monitor cases (of asthma and COPD)
    according to severity
  • Recognize long term complications like
    respiratory failure and cor pulmonale

5
Illustrative Cases
6
Case 1
  • Mohan, a 15 year old boy presents with
  • History of episodes of breathlessness, dry cough
    and wheeze for the past 3 years
  • These symptoms usually occur early in the morning
    and are worsened with change of season
  • These also become more severe while playing
    cricket with his friends
  • He also has history of repeated episodes of
    sneezing, itchy eyes and clear discharge from the
    nose
  • His mother had a history of similar symptoms when
    she was his age

7
Case 1
  • On physical examination
  • Mohan is comfortable while he is being examined
  • Vital signs afebrile, respiratory rate (RR)
    17/min, heart rate (HR) 82/min, blood pressure
    (BP) 118/76 mmHg
  • GPE- no cyanosis, finger clubbing or stridor is
    evident
  • Chest examination - no hyperinflation, use of
    accessory muscles or chest wall retractions.
    Auscultation - prolonged expiratory phase along
    with diffuse inspiratory and expiratory rhonchi

8
Case 1
  • What is your provisional diagnosis?

Asthma with allergic rhinitis
9
Case 1
  • How was the diagnosis of asthma made clinically?

The patient has typical symptoms of asthma
10
Asthma
  • Symptoms
  • The four basic respiratory symptoms generally
    associated with asthma are
  • Breathlessness (dyspnea)
  • Wheezing (or noisy breathing)
  • Cough
  • Chest tightness

11
Asthma
  • Symptoms
  • A patient may present with a variable combination
    of one or more symptoms or in between episodes
    may be entirely asymptomatic
  • Symptoms typically tend to be variable,
    intermittent and recurrent
  • Presence of these symptoms in particular during
    night or early morning generally indicates the
    presence of asthma
  • These symptoms also tend to worsen after exposure
    to nonspecific triggers

12
Asthma
  • Physical signs
  • Examination of the chest is normal if patient
    presents during an asymptomatic phase of his
    illness
  • Examination of the skin and upper respiratory
    tract can provide useful information on the
    atopic status
  • Hyper-inflated chest may be seen in patients with
    long standing disease

13
Asthma
  • Physical signs
  • On auscultation, rhonchi (bilateral, diffuse,
    polyphonic, predominantly expiratory) are
    prominent
  • Tachypnea, tachycardia and use of accessory
    muscles of respiration suggest severe
    exacerbation
  • Presence of cyanosis and a silent chest
    indicate life threatening exacerbation

14
Asthma
  • Points to remember
  • Asthma is largely a clinical diagnosis a
    detailed history and careful physical examination
    is essential to make a correct clinical diagnosis
    of asthma in most instances
  • Investigations are generally required only if the
    diagnosis of asthma is in doubt or other
    conditions are suspected to complicate asthma
    (this generally implies a referral to a secondary
    health care level)

15
Case 1
  • How will you investigate the patient further?

At this point of time, treatment may be initiated
without any further investigations since asthma
is a clinical diagnosis. However, if there is a
doubt about the diagnosis, or presence of an
alternative diagnosis or complication, the
patient should be referred for investigations
and confirmation of diagnosis.
16
Investigations
  • SPUTUM FOR ACID-FAST BACILLI to exclude
    tuberculosis if the patient has persistent cough
    and expectoration for gt 3 weeks
  • SPIROMETRY
  • It is not mandatory but should be performed if
    the clinical data is confusing
  • It provides an objective measurement of the
    presence and severity of airflow
    obstruction/limitation
  • Demonstration of bronchodilator reversibility is
    helpful in making a more confident diagnosis of
    asthma and excluding COPD

17
Investigations
  • PEF
  • Although not very accurate, Peak Expiratory Flow
    (PEF) measurements may be used as supportive
    evidence in the absence of spirometry
  • CHEST RADIOGRAPH
  • To exclude bronchiectasis, lung cancer and
    interstitial lung diseases
  • HEMOGRAM
  • If there is a possibility of anemia as the cause
    for dyspnea
  • ELECTROCARDIOGRAM
  • For the diagnosis of cardiac disorders like
    congestive heart failure that often mimic asthma

18
Case 2
  • Ram Lal, a 53 year old farmer presents with
  • History of chronic cough and 15-20 ml of clear
    sputum daily for the past 8 years
  • History of increasing breathlessness for 3 years
    that was initially on climbing stairs but
    gradually worsened with time and now he can
    barely walk to his fields half a kilometer away
  • He denies any acute changes in either his
    breathing or the cough and sputum production and
    also denies presence of chest pain, hemoptysis or
    wheezing
  • He smoked one pack of bidis/day for 30 years but
    quit smoking 3 months ago because of dyspnea
  • He takes no medications regularly

19
Case 2
  • On Physical Examination
  • Ram Lal is a thin man who appears older than his
    stated age
  • He is conscious and alert
  • Vital signs - afebrile, RR 22/min, HR 110/min, BP
    140/90 mmHg
  • His chest is barrel shaped (increased
    antero-posterior diameter) with hyper-resonant
    note, decreased intensity of breath sounds and
    crackles in bases
  • Rest of the physical examination is unremarkable

20
Case 2
  • What is your provisional diagnosis?

COPD
21
Case 2
  • How was the diagnosis suspected clinically?

The patient has symptoms and signs suggestive of
COPD
22
COPD
  • Symptoms
  • The important respiratory symptoms generally
    associated with COPD are
  • Chronic cough which may be intermittent or
    present throughout the day
  • Chronic sputum production sputum can be mucoid
    or mucopurulent and is present on most days for
    at least 3 months in a year for 2 consecutive
    years
  • Both cough and sputum production are
    characteristically more in the early morning

23
COPD
  • Symptoms
  • Breathlessness may not be present initially,
    tends to progress with time worse on exercise
    and during acute exacerbations
  • Physical Signs
  • Rarely diagnostic and often not present until
    significant impairment of lung function has
    occurred
  • Certain findings on clinical examination point
    towards the diagnosis of COPD

24
COPD
  • Physical signs
  • Pursed lip breathing, use of accessory
    respiratory muscles, indrawing of lower
    intercostal spaces
  • Features of hyperinflation - increased
    antero-posterior diameter and hyper-resonant
    percussion
  • Uniformly diminished intensity of breath sounds
    with a prolonged expiratory phase, fine
    inspiratory crepitations, rhonchi (relatively
    less pronounced as compared to asthma)

25
Case 2
  • What are the investigations that you should order
    to confirm the diagnosis?

At this point of time, Ram Lal should undergo
sputum testing for AFB (at the nearest DOTS
centre to rule out tuberculosis) and if
negative, should be initiated on treatment for
COPD
26
COPD
  • Diagnosis
  • Investigations are generally required in patients
    with suspected COPD for
  • Confirmation of diagnosis of COPD
  • Exclusion of alternate diagnosis
  • Assessment of severity
  • Diagnosis of complications

27
Investigations
  • SPUTUM FOR ACID-FAST BACILLI
  • to exclude tuberculosis
  • SPIROMETRY
  • Gold standard for confirmation staging of COPD
  • Bronchodilator reversibility is useful to rule
    out a diagnosis of asthma and establish patients
    best attainable lung function
  • PEF
  • may be used for diagnosing airflow limitation
    (and testing bronchodilator reversibility) when
    spirometry is not available

28
Investigations
  • CHEST RADIOGRAPH
  • to exclude alternate diagnosis (bronchiectasis,
    lung cancer etc) detect complications such as
    cor pulmonale, pneumothorax or pneumonia
  • HEMOGRAM
  • ELECTROCARDIOGRAM
  • useful in diagnosing cardiac disorders as well as
    detecting complications of COPD (like cor
    pulmonale)

29
(No Transcript)
30
Case 3
  • Rani, a 26 year old lady presents with
  • History of breathlessness, wheezing and cough
    with minimal mucoid expectoration since the age
    of 12 years
  • Initially these symptoms were episodic, usually
    occurring with change of season but with time,
    symptoms have became more severe and episodicity
    has been lost and now she has persistent symptoms
    throughout the year
  • Her husband is a chronic smoker who smokes around
    10 bidis per day
  • She cooks food by burning dried wood and dung

31
Case 3
  • She has been treated by several physicians in the
    past and has been prescribed different drugs
    including oral salbutamol, oral prednisolone and
    inhaled salbutamol
  • Presently, her symptoms interrupt her sleep 3-4
    times per week and even during the day, she is
    unable to carry out her day to day activities
  • Spirometry done outside shows moderate
    obstruction and significant bronchodilator
    reversibility

32
Case 3
  • What is the diagnosis (COPD or asthma)?
  • What is the severity of the patients disease?

Rani has asthma - based on her symptoms and
reversible airflow obstruction on spirometry,
her asthma is of moderate severity
33
Asthma Severity Classification
34
Case 3
  • What are the goals that are to be kept in mind
    while managing Ranis asthma?

35
Asthma
  • Management Includes the following goals
  • Achieve and maintain control of symptoms
  • Minimal (ideally no) chronic symptoms, including
    nocturnal symptoms
  • Prevent asthma episodes or attacks
  • Minimal (infrequent) exacerbations
  • No (or infrequent) emergency visits
  • Minimal (ideally no) need for reliever medication
  • Maintain normal activity levels
  • No limitations on activities, including exercise
  • No absenteeism from work place

36
Asthma
  • Management Includes the following goals
  • Avoid adverse effects from asthma medications
  • Identification and appropriate treatment of
    associated conditions like rhinitis, sinusitis
    and GERD
  • Prevent asthma mortality

37
Asthma
  • Management
  • Asthma can be effectively controlled in most
    patients, although it can not be cured
  • The most effective management is to prevent
    airway inflammation by eliminating the causal
    factors
  • The major factors contributing to asthma
    morbidity and mortality are under-diagnosis and
    inappropriate treatment

38
Case 3
  • What is the initial treatment that would be
    appropriate for this patient?

She should be initiated on controller medication
such as inhaled corticosteroids (ICS) with an
inhaled long-acting ß2-agonist (LABA) either by
metered dose inhaler (MDI preferably with
spacer) or dry powder inhaler (DPI). It should
be emphasized that these medications should be
taken regularly even if she is not having any
symptoms. Reliever medication such as inhaled
short-acting ß2-agonists (SABA) should also be
prescribed with the instructions that it is to be
taken strictly on an as-required basis and not
as a substitute for the controller drug(s)
39
Asthma
  • Management (Pharmacological)
  • A stepwise approach to pharmacological therapy is
    recommended
  • The aim is to achieve asthma control with the
    least possible medication
  • The choice of treatment should be guided by
  • severity of the patients asthma
  • availability of various drugs and devices for
    asthma treatment in and around the patients
    place of living
  • economic considerations

40
Asthma
  • Management (Pharmacological)
  • Controllers Medications also known as
    prophylactic, preventive or maintenance
    medications
  • Are required to be taken daily in order to keep
    asthma under control and include the following
  • Inhaled corticosteroids (ICS) most important
  • Inhaled long-acting ß2-agonists (LABA)
  • Sustained release methylxanthines
  • Oral long-acting ß2-agonists
  • Leukotriene modifiers
  • Systemic glucocorticosteroids
  • Cromones

41
Asthma
  • Management (Pharmacological)
  • Reliever Medications
  • Also known as quick relief or rescue medications
    - taken only on as required basis for immediate
    relief
  • Include the following
  • Inhaled short-acting ß2-agonists (SABA) most
    important
  • Systemic glucocorticosteroids
  • Anticholinergic agents
  • Methylxanthines
  • Oral short-acting ß2-agonists

42
Asthma
  • Points to remember
  • If asthma symptoms are more than intermittent (gt
    twice a week), it is more appropriate to control
    the disease by prescribing maintenance drugs that
    control inflammation (use of ICS) rather than by
    giving relievers (use of inhaled SABA)

43
Asthma
  • Management (Pharmacological)
  • Inhaled Corticosteroids (ICS)
  • Most important component of asthma management
  • At present, they are the most effective
    controller medications available
  • Recommended for all patients who have persistent
    asthma
  • Long-term treatment with ICS markedly reduces the
    frequency and severity of exacerbations
  • Benefit of daily use - fewer symptoms, fewer
    severe exacerbations, reduced use of relievers,
    improved lung function, reduced airway
    inflammation

44
Asthma
  • Management (Pharmacological)
  • Inhaled Corticosteroids (ICS)
  • The risk for systemic adverse events at
    recommended dosages is very small. However, local
    side effects like oropharyngeal candidiasis,
    hoarseness of voice and throat irritation can
    occur
  • Reduce potential for adverse events by
  • Using spacer and/or rinsing mouth
  • Using lowest dose possible

45
Asthma
  • Management (Pharmacological)
  • Systemic glucocorticoids are
  • Not recommended in treatment of stable asthma
  • Rarely required in severe asthma (lowest dose to
    control symptoms, alternate day if possible)
  • Important in treatment of moderate to severe
    exacerbations of asthma
  • Oral prednisolone 40 mg per day
  • Intravenous hydrocortisone maximum 400 mg per day
    or its equivalent
  • No advantage of methylprednisolone over
    hydrocortisone

46
Asthma
  • Management (Pharmacological)
  • Methylxanthines
  • Mild disease (as an alternative to ICS)
  • As add on therapy to low to high dose ICS
    (moderate or severe disease) they improve lung
    function, prevent need for short-acting
    beta2-agonists and prevent exacerbations
  • Acute severe asthma in adults and children when
    standard treatment not effective slow
    intravenous infusion may be added to standard
    treatment if patient is not responding

47
Asthma
  • Management (Pharmacological)
  • Long-acting inhaled ß2-agonists (LABA)
  • Should always be combined with ICS
  • Not appropriate for monotherapy
  • Not a substitute for anti-inflammatory therapy
  • This combination is useful in patients with
    moderate to severe asthma (patients with
    persistent asthma symptoms)
  • Not useful for acute symptoms or exacerbations

48
Asthma
  • Management (Pharmacological)
  • Short-acting inhaled ß2-agonists (SABA)
  • Useful reliever medication in asthma most
    effective medication for relief of acute
    bronchospasm in acute exacerbations of asthma,
    and prevention of exercise induced asthma
  • Requirement of more than 2 times/week suggests
    inadequate asthma control
  • Regularly scheduled use is not generally
    recommended as it lowers effectiveness and
    increases airway hyperresponsiveness

49
Asthma
  • Management (Pharmacological)
  • Leukotriene receptor antagonist (LTRA)
  • Add on therapy in moderate to severe asthma
  • Aspirin-sensitive asthma
  • Less effective than ICS
  • Anticholinergic drugs
  • Additive effect with SABA for asthma
    exacerbations
  • Cromones
  • Mild persistent asthma
  • Exercise induced asthma (particularly in
    children)

50
Asthma
  • Management (Pharmacological)
  • Route of Administration - Inhalation route
  • Preferred mode of drug delivery
  • Easy, safe, faster onset of action
  • More effective than oral route
  • Drugs can be given by metered dose inhalers
    (MDI), dry powder inhalers (DPI) or nebulizers
  • Patients should be instructed regarding proper
    use of the inhaler device
  • Technique should be checked regularly

51
Asthma
  • Management (Pharmacological)
  • Route of Administration - Inhalation route
  • MDI with spacer/holding chamber is the preferred
    device for aerosol delivery, is less expensive
    (compared to DPI and nebulization), is as
    effective as nebulized aerosol delivery and thus
    leads to a lesser dose and lesser side-effects
  • DPI is easier to use, but costlier
  • Route of Administration - Intravenous route
  • No benefits over inhalational route
  • Potential for increased adverse effects
  • Avoid if possible

52
Asthma
  • Management (Pharmacological)
  • Route of Administration - Oral route
  • Should be avoided
  • Maintenance therapy
  • Sustained-release theophylline in mild asthma
  • Low-dose steroid in severe uncontrolled asthma
  • Long-acting Oral ß2 agonists (if patient unable
    to take inhaled bronchodilators)
  • Disadvantages
  • Systemic side-effects
  • Slower onset of action

53
Asthma Management based on severity
54
Asthma Management based on severity
  • Mild asthma and intermittent symptoms - vast
    majority of patients do not require any daily
    medication - a rapid-acting inhaled
    bronchodilator (like SABA) may be taken as needed
    to relieve asthma symptoms
  • Mild asthma and persistent symptoms daily
    controller medication (preferably ICS) required
    to achieve and maintain control of their asthma
    (sustained-release theophylline or cromones are
    alternatives if ICS are not being used by the
    patient) SABA may be taken in addition on an
    as-needed basis for immediate relief from asthma
    symptoms

55
Asthma Management based on severity
  • Moderate asthma - combination of ICS and inhaled
    LABA twice daily preferred (sustained-release
    theophylline or a LTRA or oral LABA are
    alternatives to inhaled LABA in this combination
    therapy while high dose ICS alone can be used as
    an alternative to combination therapy per se)
  • Severe asthma - combination of high dose ICS plus
    inhaled LABA twice daily preferred. Sustained
    release theophylline or a LTRA or oral LABA or a
    combination of these may be added to inhaled
    drugs if symptoms not controlled with inhaled
    drugs. Oral corticosteroids may also be
    considered in very severe cases

56
Asthma Management based on severity
Day-time symptoms lt 1/week and night-time
symptoms ? 2/month - manage with reliever
medications alone Use of reliever medications gt
1/week use controllers Reliever medications -
taken as needed to prevent symptoms but not more
than 3/day - requirement gt 2/week indicates poor
control Once the goals for asthma achieved for at
least three months - gradually reduce maintenance
therapy - 25 reduction every three months Once
the patient is off all asthma medications
follow-up every six months
57
Case 3
  • In addition to prescribing drug therapy, what
    else can you do for Rani?
  • When will you call her for follow up (F/U)?

Her husband should be advised to quit smoking
since her asthma is likely to have been
aggravated by environmental tobacco smoke (ETS)
exposure. She should avoid exposure to smoke
while cooking (smokeless chullahs , improved
Ventilation). F/U - Rani should come for F/U
regularly till her symptoms are controlled -
after this, the frequency of F/U visits should
be reduced to one visit every 3 months. She
should report immediately in case of any
worsening of symptoms or increasing requirement
of reliever medications
58
Asthma
  • Management (Non-pharmacological)
  • Patient education
  • Education of patients assists in the management
    of their disease, helps them get the ability to
    attempt controlling their disease by themselves
    and establishes good rapport between the
    physician and patients
  • Should be a continuous process and should include
    both the patient and his family members. It
    should help establish a partnership among
    physician, the patient and the family members.
  • Should provide information about the disease and
    help them learn self-management skills

59
Asthma
  • Management (Non-pharmacological)
  • Patient education
  • Factors leading to poor compliance with
    medications include difficulties with use of
    inhaler drugs including device usage, complicated
    regimens and prescriptions, fears about or actual
    side effects and cost of treatment
  • Other factors include misunderstanding or lack of
    information in patients, underestimation of
    disease severity by physician, health attitude of
    patient and family members, cultural factors and
    poor communication between physician and patients

60
Asthma
  • Management (Non-pharmacological)
  • Avoidance of exposure to risk factors
  • Use of measures that reduce exposure to noxious
    agents is known to decrease asthma exacerbations
  • Hence attempt should be made to reduce exposure
    to indoor allergens, tobacco smoke, vehicle
    emission, avoiding specific foods and medications
    (identified by patients or their family members
    to trigger exacerbations) and irritants in the
    workplace

61
Asthma
  • Management (Non-pharmacological)
  • Ensuring regular follow-up
  • This is essential for monitoring of the patients
    clinical status and ensuring that goals of asthma
    management are being met
  • During each visit, the physician should review
    symptom profiles (day time and nocturnal),
    requirement for reliever medications, compliance
    with controller medications and home PEF record
    (if patient is using a PEF meter at home)

62
Asthma
  • Management (Non-pharmacological)
  • Ensuring regular follow-up
  • Assess technique of using devices for inhaled
    medications as well as risk factors for
    exacerbations (identify and advise their
    avoidance/control)
  • Once asthma is controlled, frequency of follow-up
    visits can be reduced gradually. However no more
    than 3 months (or 6 months if patient comes from
    a remote area) should elapse between consecutive
    visits
  • The decision to step up/step down the treatment
    should also be taken during follow up visits

63
(No Transcript)
64
Case 4
  • Shanti Devi, a 58 year old lady presents with
  • History of cough with expectoration and wheezing
    for the last 6 years. The symptoms used to worsen
    in the winters with episodes associated with
    fever and increased quantity of mucopurulent
    sputum that used to get relieved with short
    courses of oral medications prescribed by local
    practitioners. However, she was not taking any
    medications on a regular basis
  • She denies history of smoking but her husband who
    passed away recently had been a chronic smoker
    who used to smoke 2 packs of cigarettes everyday

65
Case 4
  • For the past 1 year her shortness of breath has
    increased progressively. During this time she
    underwent an ECG and a chest x-ray both of which
    were reported as being normal. Subsequently, she
    was prescribed oral salbutamol that she took for
    a few days but stopped since she had started
    experiencing trembling of hands

66
Case 4
  • What is the diagnosis (COPD or asthma)?
  • What is the severity of the patients disease?

Shanti Devi has COPD - based on her symptoms and
signs, she has moderate COPD
67
COPD Severity staging without spirometry
68
COPD Severity staging with spirometry
69
Case 4
  • What are the goals that are to be kept in mind
    while managing Shanti Devis COPD?

70
COPD
  • Management Goals
  • Relieve symptoms
  • Avoidance of risk factors
  • Improve exercise tolerance
  • Improve health status
  • Prevent and treat exacerbations
  • Prevent and treat complications
  • Reduce mortality
  • Minimize side effects from treatment

71
COPD
  • Management
  • The following should be considered while
    formulating a management plan
  • Severity of the patients disease
  • Benefits and risks to the individual
  • Direct and indirect costs to the individual
    and/or his/her family members
  • Availability of various drugs and devices for
    treatment in and around the patients place of
    living

72
Case 4
  • What is the initial treatment that would be
    appropriate for this patient?

She should be initiated on inhaled
bronchodilators - a combination of inhaled long
acting anticholinergic (tiotropium) with an
inhaled LABA (e.g. formoterol) may be an
appropriate initial choice. Reliever medication
(inhaled SABA) should also be prescribed on an
as-needed basis. If her symptoms are not
controlled, sustained release oral theophylline
preparations may be added to inhaled drugs. She
also may benefit from the addition of ICS in high
doses
73
COPD Management according to severity
Tobacco cessation and pulmonary rehabilitation
are important at all stages
74
COPD Management based on severity
  • At risk (stage 0) cessation to smoking (or
    other forms of tobacco) exposure is the only
    intervention required for patients in this stage
  • Mild COPD (stage 1) rapid-acting inhaled
    bronchodilator (like SABA or ipratropium) may be
    taken as needed to relieve symptoms
    (sustained-release theophylline is an alternative
    if patient is not taking inhaled drugs)

75
COPD Management based on severity
  • Moderate COPD (stage 2) long acting inhaled
    bronchodilators are preferred (inhaled tiotropium
    with/without inhaled LABA) - sustained-release
    theophylline or oral LABA or a combination of
    these may be added to inhaled drugs if symptoms
    not controlled with inhaled drugs (they can also
    be alternatives if patient is not taking inhaled
    drugs)
  • Severe COPD (stage 3) - high dose ICS should be
    added to bronchodilator therapy (as described for
    moderate COPD) it is equally important to
    detect and treat complications

76
COPD
  • Management (Pharmacological)
  • None of the existing medications for COPD has
    been shown to modify the long-term decline in
    lung function that is the hallmark of this
    disease
  • Therefore, pharmacotherapy for COPD is used to
    decrease symptoms and/or complications

77
COPD
  • Management (Pharmacological)
  • Bronchodilator medications
  • central to symptom management
  • prescribed on an as-needed or regular basis to
    reduce symptoms
  • inhaled therapy is preferred
  • long-acting inhaled bronchodilators are more
    convenient
  • choice between bronchodilators or combination
    therapy from different classes of bronchodilators
    depends on availability and individual response

78
COPD
  • Management (Pharmacological)
  • Choice of Bronchodilators Combining
    bronchodilators may improve efficacy and decrease
    the risk of side effects compared to increasing
    the dose of a single bronchodilator
  • Anticholinergics (Inhaled) tiotropium,
    ipratropium
  • Beta-agonists (Preferably inhaled) LABA, SABA
  • Combination of inhaled anticholinergic and
    beta-agonists
  • Oral theophyllines

79
COPD
  • Management (Pharmacological)
  • Anticholinergics
  • cause effective bronchodilation
  • reduce rate and severity of acute exacerbations
  • improve quality of life
  • side effects include dryness, blurred vision etc.
  • Corticosteroids
  • indicated for moderate to severe stable COPD
    (inhaled) and for acute exacerbations
    (oral/parenteral)
  • help by improving lung functions, reducing
    exacerbations, improving symptoms and quality of
    life and reducing airway reactivity

80
Case 4
  • In addition to prescribing drug therapy, what
    else can you do for Shanti Devi?

She should be educated about her disease and the
need for avoidance of risk factors and should be
kept on regular follow up
81
COPD
  • Management (Non-pharmacological)
  • Patient education (same as for asthma)
  • Avoidance of exposure to risk factors
  • Pulmonary Rehabilitation (referral to a higher
    centre)
  • Regular follow up (same as for asthma)

82
COPD
  • Management (Non-pharmacological)
  • Avoidance of exposure to risk factors
  • Reduction of total personal exposure to tobacco
    smoke, occupational dusts and chemicals, and
    indoor and outdoor air pollutants are important
    goals to prevent the progression of COPD
  • Smoking cessation is the single most effective
    (and cost-effective) intervention to reduce the
    risk of developing COPD and stop its progression

83
COPD Management
Brief strategies to help the patient willing to
quit smoking
84
COPD
  • Management (Non pharmacological)
  • Avoidance of exposure to other risk factors
  • Avoiding open burning of crop residue
  • Use of water to suppress dust
  • Wearing masks at work place in areas of dust
    generation
  • Reducing risk associated with solid fuel
    combustion by using smokeless chullahs
  • Substitution of solid fuels with LPG or
    electricity
  • Kitchens should be adequately ventilated

85
COPD
  • When to refer?
  • There is a strong suspicion of an alternate
    diagnosis
  • Patient is not responding to treatment
  • Presence of complications like chronic cor
    pulmonale, respiratory failure or pneumothorax
  • Assistance in tobacco cessation and/or pulmonary
    rehabilitation

86
Algorithm for diagnosis and management of COPD at
different levels of health care
Patient reporting with suggestive respiratory
symptoms
- H/o exposure to risk factors - Physical
examination - Exclude other diseases
Sputum for AFB x 3
ve
-ve
Refer to nearest DOTS centre (RNTCP) or start ATT
Provisional diagnosis COPD
Secondary care level
Complications
Spirometry / Chest X-ray
- Spirometry / Chest X-ray if feasible -
Treatment as per guidelines
  • Intensive care for acute exacerbation
  • Rehabilitation for stabilized patient
    domiciliary oxygen, appropriate nutrition and
    respiratory physiotherapy

Good response
Poor response
Treatment
Continue treatment
Complications
Good response
Poor response
Follow up
Good response
Tertiary Care Level
Secondary Care Level
Primary Care Level
87
Case 5
  • Pritam, a 52 year old businessman presents with
  • History of shortness of breath and wheezing for
    the past 2 months. These symptoms tend to worsen
    while lying down and recently he has noted that
    his sleep is often disrupted by severe
    breathlessness associated with uneasiness and
    profuse sweating - this gets relieved in a few
    minutes by sitting up and walking around
  • He denies history of chest pain or cough with
    expectoration
  • He is a known case of hypertension and diabetes
    mellitus for the past 10 years
  • He is a life long non-smoker

88
Case 5
  • On Physical Examination
  • Pritam is an obese gentleman of short stature
  • Vital signs afebrile, RR 32/min, HR 110/min, BP
    180/100 mmHg
  • Chest - vesicular breath sounds with normal
    intensity are heard throughout lung fields fine
    end-inspiratory crackles are heard in both bases
  • CVS - S1 and S2 are normally heard a systolic
    murmur is heard over the apex
  • Rest of the physical examination is unremarkable

89
Case 5
  • What is your provisional diagnosis?

Pritam has left ventricular failure
90
Case 5
  • How was the diagnosis suspected clinically?

Even though the patient is a non-smoker and has
symptoms of wheezing and breathlessness, the
diagnosis is not asthma because in addition, he
has orthopnoea and paroxsymal nocturnal dyspnoea
in association with obesity, diabetes mellitus
and hypertension, all of which are suggestive of
ischemic heart disease and left ventricular
failure
91
Case 5
  • What are the investigations that you should order
    to confirm the diagnosis?

He should undergo ECG and echocardiography and
be initiated on treatment for heart failure.
Referral to a secondary care level for further
evaluation and management should be appropriate
92
Case 6
  • Pushkar, a 46 year old male presents with
  • History of cough with expectoration,
    breathlessness and fever for the past 3 months
  • He has also noticed streaky hemoptysis as well as
    weight loss of approximately 6 kg and a reduction
    in appetite
  • He denies history of wheezing or chest pain
  • He is a chronic smoker who smoke around 15 bidis
    per day

93
Case 6
  • On Physical Examination
  • Vital signs - T 100.9ºF (38.3ºC), RR 22/min, HR
    90/min, BP 114/82 mmHg
  • Chest - bronchial breath sounds are heard over
    the left infraclavicular and suprascapular areas
    with inspiratory and expiratory crackles in the
    same areas while normal vesicular breath sounds
    are heard in the other areas.
  • CVS S1 and S2 are normally heard
  • Rest of the physical examination is unremarkable

94
Case 6
  • What is your provisional diagnosis?

Pulmonary Tuberculosis
95
Case 6
  • How was the diagnosis suspected clinically?

Even though the patient is a smoker and has
symptoms of cough with expectoration and
breathlessness, the diagnosis is not COPD
because in addition, he has hemoptysis, fever
and constitutional symptoms, all of which are
suggestive of active pulmonary tuberculosis
96
Case 6
  • What are the investigations that you should order
    to confirm the diagnosis?

He should undergo sputum analysis for acid fast
bacilli and chest x-ray
97
Differential Diagnosis
  • Symptoms
  • One should get alerted to the possibility of
    presence of an alternative or a coexisting
    disease if the following exist
  • fever
  • weight loss
  • hemoptysis
  • excessive and purulent sputum
  • chest pain
  • orthopnea and paroxysmal nocturnal dyspnea
  • Such diseases could include bronchiectasis,
    tuberculosis, ischemic heart disease, left
    ventricular failure and lung cancer

98
Differential Diagnosis
  • Signs
  • Presence of one or more of the following (on
    physical examination) indicates an
    alternative/coexisting disease
  • Fever
  • Purulent sputum
  • Finger clubbing
  • Localized physical findings
  • Evidence of fibrocavitary disease
  • Heart murmurs or additional heart sounds

99
Summary
100
Asthma
  • Think of asthma when
  • Onset of symptoms at an early age
  • Intermittent symptoms
  • Family history of atopy/asthma or personal
    history of atopy
  • Non-smoker
  • Pronounced wheezing
  • Good response to inhaled bronchodilators and
    steroids

101
Asthma
  • The physician should remember
  • Asthma can be effectively controlled, although it
    cannot be cured
  • Effective asthma management programs include
    education, environmental control and
    pharmacologic therapy
  • A stepwise approach to pharmacologic therapy is
    recommended. The aim is to accomplish the goals
    of therapy with the least possible medication

102
COPD
  • Think of COPD when
  • Onset of symptoms later in life
  • Progressive symptoms and absence of symptom free
    periods
  • Tobacco smoker (bidi/cigarette/hukkah etc.)
  • Reduction in intensity of breath sounds
    pronounced wheeze not prominent
  • Not very good response to inhaled bronchodilators
    and steroids

103
COPD
  • The physician should remember
  • Development of COPD can be prevented by avoiding
    exposure to risk factors
  • Effective COPD management programs include
    reducing exposure to risk factors, pharmacologic
    therapy and rehabilitation
  • Pharmacologic therapy cannot alter the natural
    course of the disease and is only for relief of
    symptoms. Smoking cessation is the most effective
    and proven intervention that has been shown to
    reduce mortality in COPD

104
Appendix A Overview of asthma and COPD
105
Introduction Overview
  • COPD and asthma are
  • Diseases characterized by airflow obstruction
  • Associated with chronic inflammation of the
    airways
  • Common worldwide
  • Associated with significant morbidity and
    mortality
  • They differ in the
  • Extent of reversibility of airflow obstruction
  • Clinical features and natural history
  • Type of cellular inflammation involved

106
Airflow limitation resulting from a variable
mixture of loss of alveolar attachments,
inflammatory obstruction of the airway and
luminal obstruction with mucus
Peter J Barnes. Chronic Obstructive Pulmonary
Disease. N Engl J Med 2000 343 269-280.
(Reproduced with permission)
107
NORMAL AIRWAY
AIRWAY IN PATIENTS WITH AIRFLOW OBSTRUCTION
Airway lumen
Airway wall
Smooth muscle
Mucus glands
Smooth muscle hypertrophy
Inflammation and edema
Airway narrowing
Mucus plugging
Mucus gland hypertrophy and hyperplasia
108
Introduction Overview
  • COPD
  • Includes chronic bronchitis and emphysema
  • It is generally difficult to separate out the two
    conditions, hence they are grouped together as
    COPD
  • Currently it is the 5th leading cause of death in
    the world (4.8 of all deaths in 2002)
  • Further increases in prevalence and mortality are
    predicted (7.9 of all deaths by 2030)

109
Introduction Overview
  • Risk factors for COPD
  • Tobacco smoking (active or passive) is a major
    predisposing factor for the development of COPD
  • Passive smoking is now more appropriately known
    as environmental tobacco smoke (ETS) exposure
  • Both cigarette and bidi smoking are equally
    responsible

110
Introduction Overview
  • Additional risk factors for COPD
  • These are particularly important for COPD
    occurring in non-smoking individuals
  • Indoor air pollution like exposure to solid
    combustion fuels/biomass fuels (such as dried
    dung, wood and crop residue) when they are used
    for cooking
  • Outdoor air pollution like
  • exhausts from vehicles and industrial units
  • dusts, fumes and smoke from burning of crop
    residues in the field
  • Low socioeconomic status

111
Introduction Overview
  • COPD
  • In the Global Burden of Disease Study, prevalence
    was estimated to be
  • 9.34 per 1,000 males 7.33 per 1,000 females
    (worldwide)
  • 4.38 per 1,000 males 3.44 per 1,000 females
    (India)
  • In a recent large multi-centre population based
    Indian study, the prevalence of COPD was found to
    be
  • 4.1 among adult subjects aged 35 years and above
  • 8.2 5.9 among bidi cigarette smokers
    respectively

112
Introduction Overview
  • Natural history of COPD
  • Development and progression of COPD can vary
    between individuals
  • Generally, the disease tends to progress with
    time (especially if a patient's exposure to risk
    factors continues)
  • Course is punctuated with repeated exacerbations
  • (defined as a sustained increase in symptoms
    that can culminate in hospitalization,
    respiratory failure and ultimately death)
  • Exacerbations are more common in patients with
    lower levels of lung function and may lead to
    further (as well as rapid) declines in lung
    function

113
Introduction Overview
  • Natural history of COPD
  • Stopping exposure to risk factors will slow down
    or even halt the progression of disease (and can
    result in some improvement in function) even in
    advanced stages of the disease
  • In addition to risk factors, lung function, body
    mass index, exercise capability, severity of
    dyspnea, and presence of co-morbid diseases
    determine the outcome in COPD

114
Introduction Overview
  • Asthma
  • Asthma is one of the most common chronic diseases
    worldwide and is a major cause of school/work
    absence
  • Poorly controlled asthma is expensive and health
    care expenditures are very high
  • Investment in prevention medication likely to
    yield cost savings in emergency care
  • Prevalence increasing in many countries,
    especially in children

115
Introduction Overview
  • Asthma
  • The estimated prevalence of asthma is believed to
    be 100 to 150 million worldwide and 15-20 million
    in India
  • Worldwide around 180000 people per year die of
    asthma
  • An overall increase in severity of asthma
    increases the pool of patients at risk for death
  • In a recent large multi-centric Indian study
    involving adult subjects aged 15 years and above,
    asthma was present in 2.38

116
Introduction Overview
  • Risk factors for Asthma
  • Host Risk Factors
  • Atopy (production of abnormal amounts of IgE
    antibodies in response to common environmental
    allergens) is one of the strongest identifiable
    predisposing factor for developing asthma
  • Family history of asthma or atopy

117
Introduction Overview
  • Risk factors for Asthma
  • Environmental Risk Factors
  • Allergens (Indoor and Outdoor) house dust mites,
    allergens from insects and pet animals fungi,
    molds and yeasts pollens
  • Tobacco smoke (active and ETS exposure)
  • Air pollution (outdoor and indoor) smoke and
    fumes including use of biomass fuels for cooking
  • Occupational exposures

118
Introduction Overview
  • Triggers for Asthma
  • Triggers Factors which precipitate an
    exacerbation in a stable or previously
    asymptomatic patient
  • Respiratory infections (usually viral)
  • Allergens (indoor/outdoor)
  • Air pollution (indoor/outdoor)
  • Tobacco smoke (active and ETS exposure)
  • Drugs - Beta-blockers and NSAIDs
  • Exercise and exposure to cold, psychological or
    other unaccustomed stress

Foods are not commonly established triggers of
asthma
119
Introduction Overview
  • Natural history of Asthma
  • Natural history of asthma is variable
  • Onset can occur at any age but commonly tends to
    affect children and young adults
  • Generally severity of asthma in adult life
    parallels its severity during childhood
  • 5-10 of children with mild asthma go on to
    develop severe asthma later in life

120
Introduction Overview
  • Natural history of Asthma
  • Contrary to common belief, children do not
    necessarily grow out of asthma
  • Almost two-third continue to have symptoms in
    puberty and adulthood
  • Even the remaining one-third, in whom a clinical
    remission may be apparent, persistent lung
    function abnormalities are observed

121
Appendix B Differences and similarities between
asthma and COPD
122
Asthma COPD Similarities
  • What are the similarities between the two?
  • Common risk factors and aggravating factors
    (tobacco smoke, outdoor and indoor air pollution)
  • Symptoms (breathlessness, wheezing, cough)
  • Signs (reduced intensity of breath sounds,
    rhonchi)
  • Spirometry (obstructive pattern)

123
Asthma COPD Differences
124
Asthma COPD Differences
125
Asthma COPD Differences
126
Asthma COPD Differences
127
Asthma COPD Differences
  • Why is it important to differentiate between the
    two?
  • Prevention - Asthma is not preventable (only
    controllable) while COPD is largely preventable
  • Treatment - Inhaled corticosteroids are the
    cornerstone of treatment for all but the mildest
    cases of asthma while their utility in COPD is
    limited
  • Outcome - Asthma has a variable course while COPD
    usually progresses with time
  • Complications - Long term complications like
    pulmonary hypertension and respiratory failure
    are more likely to occur with COPD while they are
    rare in asthma

128
Appendix C Drugs their dosages
129
Equivalent doses of ICS
Medication inserts for HFA preparations should be
carefully reviewed for the correct dosage level
130
SABA
  • Includes the following drugs
  • Salbutamol
  • Terbutaline
  • Levosalbutamol
  • Effect
  • Inhaled form
  • Onset 1-5 minutes
  • Duration 3-6 hours
  • Oral form
  • Duration 6-8 hours

131
Doses of SABA (salbutamol)
132
Doses of SABA (terbutaline)
133
Long-acting drugs
  • Long-acting beta2 agonists - includes the
    following
  • Salmeterol (50 to 100 mcg/day)
  • Formoterol (12 to 24 mcg/day)
  • Formoterol has a quicker onset of action than
    salmeterol
  • Methylxanthines
  • Theophylline (oral) - sustained release
  • Adults - 300-600 mg/day
  • Children lt 1 yr- 0.2 (age in wks)5 mg/kg/day
  • Children gt 1 yr- 16 mg/kg/day
  • Doxyphylline is an alternative to theophylline
  • 200-400 mg thrice a day

134
Other Drugs
135
Appendix D Measurements and devices useful in
management of asthma and COPD
136
SPIROMETRY
  • Definitions
  • Obstructive defect FEV1/FVC ratio lt 70
  • Bronchodilator reversibility increase by 12
    AND 200 mL over the baseline values (either FVC
    or FEV1) after 200 µg of inhaled salbutamol
  • Presence of a post-bronchodilator FEV1lt80 of the
    predicted value in combination with a FEV1/FVC
    lt70 confirms the presence of airflow limitation
    that is not fully reversible

137
PEAK EXPIRATORY FLOW (PEF)
  • Although PEF meters are simpler to use than the
    spirometers, there is a high degree of
    variability and lack of reproducibility of PEF -
    hence PEF measurements are inferior to
    spirometric values
  • PEF measurements do not correlate well with FEV1
    values and cannot be used interchangeably for
    either diagnosing or staging airflow limitation
  • Can be used for monitoring the disease

138
The PEF Meter
  • Inexpensive clinic instrument
  • Useful for monitoring - allows the patient
  • to assess the status of his/her asthma

139
The PEF Meter
  • One hard, fast blow

140
PEF Monitoring
  • Patients with moderate-to-severe asthma should
    have a PEF meter and learn to monitor their PEF
  • Monitoring can be daily (long-term), short-term
    (2 to 3 weeks) and during exacerbations
  • Patients should measure PEF on waking before
    taking a bronchodilator, use their personal best
    and be aware that a peak flow lt80 of personal
    best indicates a need for additional medication
  • Patients should use the same peak flow meter over
    time

141
Metered Dose Inhaler
John Rees. Methods of delivering drugs. BMJ 2005
331 504-506. (Reproduced with permission)
142
Metered Dose Inhaler
John Rees. Methods of delivering
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