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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 health care facilities
  • The list of diseases that can cause 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 two
    important pulmonary diseases (asthma and COPD)
    with regards to their management (diagnosis based
    on clinical features/investigations and treatment)

3
Objectives
  • At the end of training, the health care provider
    should be able to
  • Evaluate a patient presenting with symptoms of
    cough, breathlessness and wheezing in order to
    suspect asthma/COPD clinically
  • Appropriately refer to a higher center for
  • Differentiation between the two main causes of
    airflow obstruction (asthma and COPD)
  • Clinical assessment of the severity of airflow
    obstruction
  • Assist in patient education, management and
    monitoring of cases (of asthma and COPD)
    according to their severity

4
Illustrative Cases
5
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

6
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
  • General Physical Examination - Normal

7
Case 1
  • What is your provisional diagnosis?

Asthma with allergic rhinitis
8
Case 1
  • How was the diagnosis of asthma made clinically?

The patient has typical symptoms of asthma
9
Asthma
  • Symptoms
  • The four basic respiratory symptoms generally
    associated with asthma are
  • Breathlessness (dyspnea)
  • Wheezing (or noisy breathing)
  • Cough
  • Chest tightness
  • A patient may be entirely asymptomatic in between
    episodes
  • 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

10
Asthma
  • Points to remember
  • Asthma is largely a clinical diagnosis a
    detailed history is essential to make a correct
    clinical diagnosis of asthma in most instances

11
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

12
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

13
Case 2
  • What is your provisional diagnosis?

COPD
14
Case 2
  • How was the diagnosis suspected clinically?

The patient has symptoms suggestive of COPD
15
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
  • Breathlessness may not be present initially,
    tends to progress with time worse on exercise
    and during acute exacerbations

16
Case 2
  • What will you do for Ram Lal further?

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 referred to a doctor
17
(No Transcript)
18
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

19
Case 3
  • She cooks food by burning dried wood and dung
  • She has been treated by several physicians in the
    past and has been prescribed different drugs
  • 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

20
Case 3
  • You referred her to the doctor suspecting asthma
    based on her symptoms
  • The doctor confirmed the diagnosis of asthma that
    is of moderate severity and prescribed inhaled
    corticosteroids (ICS) and long acting inhaled
    ß2-agonists (LABA) to be taken regularly and
    short acting inhaled ß 2-agonists (SABA) on an as
    required basis

21
Case 3
  • What are the goals that are to be kept in mind
    while managing Ranis asthma?

22
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
  • 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
  • Identification and appropriate treatment of
    associated conditions like rhinitis, sinusitis
    and gastro-esophageal reflux disease

23
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

24
Case 3
  • What would you need to explain and emphasize to
    Rani regarding the drugs prescribed to her?

Rani has been initiated on controller medications
in the form of inhaled corticosteroids (ICS)
with an inhaled long-acting ß2-agonist (LABA).
These have to be taken either by metered dose
inhaler (MDI - preferably with spacer) or by dry
powder inhaler (DPI). You have to emphasize to
Rani that these medications should be taken
regularly even if she is not having any
symptoms. Inhaled short-acting ß2-agonist SABA
is a reliever medication and it is to be taken
strictly on an as-required basis only and not as
a substitute for the controller drug(s).You also
have to help Rani in learning how to use MDI/DPI
and ensure that she rinses her mouth after using
these.
25
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 glucocorticosteroids (ICS) most
    important drug
  • Long-acting inhaled ß2-agonists (LABA)
  • Sustained release methylxanthines

26
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 inhaled ß2-agonists (SABA)
    most important drug
  • Systemic glucocorticosteroids
  • Anticholinergic agents

27
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)

28
Asthma
  • Management (Pharmacological)
  • Route of Administration - Inhalation route
  • Preferred mode of drug delivery
  • Easy, safe, faster onset of action
  • More effective than parenteral routes
  • 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

29
Asthma
  • Management (Pharmacological)
  • Route of Administration - Inhalation route
  • MDI with spacer/holding chamber is the preferred
    device best 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 - Oral route
  • Should be avoided (unless patient is unable to
    take inhaled drugs or needs to be given
    sustained-release theophylline)

30
Case 3
  • In addition to prescribing drug therapy, what
    else can you do for Rani?
  • When will you send her for follow up (F/U)?

If possible she should avoid exposure to smoke
while cooking. It can be ensured by improving
ventilation in her cooking area by use of chimney
or by use of smokeless chullahs. Regarding F/U -
Rani should be sent for follow-up 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
31
Asthma
  • Management (Non-pharmacological)
  • Patient education
  • The goal of patient education is to provide the
    patient and his/her family members with suitable
    information and training so that the patient can
    keep good health and adjust treatment according
    to a medication plan developed with the health
    care professional.
  • The key components of patient education include
  • Developing a partnership between the doctor and
    the patient
  • Getting the patient and his/her family members to
    accept that this is a continuing process

32
Asthma
  • Management (Non-pharmacological)
  • Patient education
  • Sharing of information with the patient and
    his/her family members
  • Discussing fully the expectations of the patient
    and his/her family members
  • Encouraging patient and his/her family members to
    express their fears and concerns
  • The patient requires to be
  • Provided basic information about the disease
  • Educated about the difference between relievers
    and controllers

33
Asthma
  • Management (Non-pharmacological)
  • Patient education
  • Trained in use of various inhaler devices
  • Given advice regarding prevention
  • Educated about symptoms that suggest worsening of
    asthma and steps to be taken subsequently
  • Trained in monitoring of asthma
  • Advised about how and when to seek medical
    attention
  • The patient should be regularly supervised and
    positively reinforced

34
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
  • Measures to control indoor allergens (domestic
    mites, animal allergens, cockroach allergens,
    fungi)
  • Use impermeable covers for mattresses
  • Wash all bedding in hot water (55-60 C) weekly
  • Avoid using carpets
  • Use easily washable curtains
  • Regular cleaning in case of seepage of water in
    walls/roof

35
Asthma
  • Management (Non-pharmacological)
  • Avoidance of exposure to risk factors
  • It is preferable to avoid keeping pet animals
    inside the house but it can be months before
    allergen levels decrease even after the pet
    animal has been permanently removed
  • Outdoor allergens such as pollens and molds are
    almost impossible to completely avoid. Closing
    windows and doors, remaining indoors when pollen
    and mold counts are high and using air
    conditioners, may reduce exposure during peak
    seasons (harvesting)

36
Asthma
  • Management (Non-pharmacological)
  • Avoidance of exposure to risk factors
  • Another important measure is to avoid exposure
    to passive and active smoking. Passive smoking
    increases the risk of allergic sensitization in
    children. It also increases the frequency and
    severity of symptoms in asthmatic subjects.
    Active cigarette smoking reduces treatment
    efficacy
  • Air pollution produced by combustion of cooking
    fuel, vehicular emission and industrial exhausts
    is quite harmful. At home, one of the most
    effective measures to reduce exposure to domestic
    cooking fuels is by ensuring proper ventilation
    of the kitchen

37
Asthma
  • Management (Non-pharmacological)
  • Avoidance of exposure to risk factors
  • A large number of substances have been identified
    as occupational allergens that can cause asthma.
    Ideally, the patient should be advised a change
    of occupation if feasible
  • Food allergy, as an exacerbating factor for
    asthma, is not common and occurs primarily in
    young children
  • Some medications can exacerbate asthma. These
    include aspirin and other non-steroidal
    anti-inflammatory agents, some anti hypertensive
    drugs, opiates, iodinated contrast agents and
    nitrofurantoin

38
Asthma
  • Management (Non-pharmacological)
  • Ensuring compliance and regular follow-up
  • Compliance can usually be increased
  • If the patients accepts the diagnosis of asthma
  • If he/she understands that asthma can be
    dangerous if not treated appropriately
  • If he/she is made to understand that the
    treatment is safe
  • By making the patient feel in control of his/her
    asthma
  • By ensuring good communication between the
    patient and health care professional

39
Asthma
  • Management (Non-pharmacological)
  • Ensuring compliance and regular follow-up
  • Follow up
  • Frequency of follow-up visits is reduced
    gradually, once asthma is controlled
  • However, no more than 3 months should elapse
    between consecutive visits

40
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

41
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
  • After further investigations the doctor diagnosed
    her to be having severe COPD. She was prescribed
    inhaled bronchodilators - LABA to be taken
    regularly and SABA on an as-required basis.

42
Case 4
  • What are the goals that are to be kept in mind
    while managing Shanti Devis COPD?

43
COPD
  • Management Goals
  • Relieve symptoms
  • Avoidance of risk factors
  • Improve exercise tolerance
  • Improve health status
  • Reduce mortality
  • Minimize side effects from treatment

44
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
  • Tobacco cessation and pulmonary rehabilitation
    are important at all stages

45
COPD
  • Management (Pharmacological)
  • Bronchodilator medications
  • central to symptom management
  • prescribed on an as-needed or regular basis to
    reduce symptoms
  • inhaled therapy is preferred
  • choice of bronchodilators depends on availability
    and individual response
  • combining bronchodilators may improve efficacy
    and decrease the risk of side effects compared to
    increasing the dose of a single bronchodilator

46
COPD
  • Management (Pharmacological)
  • Long-acting inhaled bronchodilators are more
    convenient
  • Commonly used bronchodilators
  • Anticholinergics (Inhaled) tiotropium,
    ipratropium
  • Beta-agonists (Preferably inhaled) LABA, SABA
  • Oral theophyllines

47
Case 4
  • In addition to monitoring drug therapy, what else
    can you do for Shanti Devi?

You have to educate her about her disease,
clarify doubts, explain how to minimize exposure
to risk factors and ensure her compliance to
treatment and regular follow up. You can also
help her in carrying out at her home, pulmonary
rehabilitation exercises taught to her
48
COPD
  • Management (Non-pharmacological)
  • Patient education (same as for asthma)
  • Avoidance of exposure to risk factors
  • Compliance and regular follow up (same as for
    asthma)
  • Pulmonary Rehabilitation (see Appendix D)

49
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

50
COPD Management
Brief strategies to help the patient willing to
quit smoking
51
COPD
  • Management (Non-pharmacological)
  • Avoidance of exposure to risk factors
  • ASK Systematically identify all tobacco users at
    every visit
  • Status of tobacco-use should be questioned and
    documented for every patient at every meeting
  • ADVISE Strongly urge all tobacco users to quit
  • In a clear, strong, and personalized manner, urge
    every tobacco user to quit

52
COPD
  • Management (Non-pharmacological)
  • Avoidance of exposure to risk factors
  • ASSESS Determine willingness to make a quit
    attempt
  • Ask every tobacco user if he or she is willing to
    make a quit attempt at this time (e.g., within
    the next 30 days)
  • ASSIST Aid the patient in quitting
  • Help the patient with a quit plan, provide
    practical counseling as well as social support.
  • ARRANGE Schedule follow-up contact

53
COPD
  • Management (Non-pharmacological)
  • Avoidance of exposure to risk factors
  • You also have to learn and teach some problem
    solving skills such as
  • Recognition of danger signals likely to be
    associated with risk of relapse (e.g. being
    around other smokers, psychosocial stress,
    getting into an argument, drinking alcohol and
    negative moods)
  • Enhancement of skills needed to handle these
    situations (e.g. learning to anticipate and
    manage or avoid a particular stress)

54
COPD
  • Management (Non-pharmacological)
  • Avoidance of exposure to risk factors
  • Basic information about smoking and successful
    quitting
  • Nature and time course of withdrawal
  • Addictive nature of smoking
  • Any return to smoking, including even a single
    puff, increases the likelihood of a relapse

55
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
  • Adequate ventilation of kitchens

56
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

57
Case 5
  • He is a known case of hypertension and diabetes
    mellitus for the past 10 years
  • He is a life long non-smoker
  • On Physical Examination
  • Pritam is an obese gentleman of short stature
  • Vital signs afebrile, RR 32/min, HR 110/min, BP
    180/100 mmHg

58
Case 5
  • What is your provisional diagnosis?

Pritam has a cardiac illness
59
Case 5
  • How was the diagnosis suspected clinically?

Even though the patient has symptoms of wheezing
and breathlessness and is a non-smoker, the
diagnosis is not asthma because his
breathlessness is significantly worse on lying
down (orthopnoea) and during sleep (paroxsymal
nocturnal dyspnoea). In addition, he has
obesity, diabetes mellitus and hypertension, all
of which predispose to heart failure. He should
be referred to a doctor immediately
60
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
  • On Physical Examination
  • Vital signs - T 100.9ºF (38.3ºC), RR 22/min, HR
    90/min, BP 114/82 mmHg

61
Case 6
  • What is your provisional diagnosis?

Pulmonary Tuberculosis
62
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. .
He should undergo sputum analysis for AFB at the
nearest DOTS center.
63
Differential Diagnosis
  • One should get alerted to the possibility of
    presence of an alternative or coexisting disease
    if the following exist
  • fever
  • weight loss
  • hemoptysis
  • excessive and purulent sputum
  • chest pain
  • orthopnea (breathlessness which worsens on lying
    down) and paroxysmal nocturnal dyspnea
    (breathlessness during sleep)
  • Such diseases could include bronchiectasis,
    tuberculosis, ischemic heart disease, left
    ventricular failure and lung cancer

64
Summary
65
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

66
Asthma
  • It should be remembered that
  • 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

67
COPD
  • Think of COPD when
  • Onset of symptoms later in life
  • Progressive symptoms and absence of symptom free
    periods
  • Tobacco smoker (bidi, cigarette or hukkah)
  • Reduction in intensity of breath sounds
    pronounced wheeze not prominent

68
COPD
  • It should be remembered that
  • 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 and long term oxygen
    therapy are the only proven interventions that
    are shown to reduce mortality in COPD

69
Appendix AOverview of asthma and COPD
70
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

71
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)
  • 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

72
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

73
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

74
Introduction Overview
  • Natural history of COPD
  • Generally, COPD tends to progress with time
    (especially if a patient's exposure to risk
    factors continues)
  • Patients may experience repeated exacerbations
  • (defined as a sustained increase in symptoms
    that can culminate in hospitalization,
    respiratory failure and ultimately death)
  • 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

75
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

76
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

77
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

78
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

79
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
80
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
  • Contrary to common belief, children do not
    necessarily grow out of asthma

81
Appendix BDifferences and similarities between
asthma and COPD
82
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)

83
Asthma COPD Differences
84
Asthma COPD Differences
85
Asthma COPD Differences
86
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
    respiratory failure are more likely to occur with
    COPD while they are rare in asthma

87
Appendix C Devices useful in management of
asthma and COPD
88
Metered Dose Inhaler
John Rees. Methods of delivering drugs. BMJ 2005
331 504-506. (Reproduced with permission)
89
Metered Dose Inhaler
John Rees. Methods of delivering drugs. BMJ 2005
331 504-506. (Reproduced with permission)
90
Technique for MDI/DPI
  • Remove the cap, hold the inhaler upright and
    shake the canister - keep the head and neck in a
    neutral position and ask the patient to exhale -
    the patient then fits the inhaler between the
    lips, actuates the inhaler (presses down on
    inhaler to release medication) as he/she starts
    to breathe in - the breathe in process should be
    deep and slow (over 3 to 5 seconds) - after
    inhalation, the patient is asked to hold his
    breath for at least 10 seconds (to allow medicine
    to reach into lungs) - repeat puffs as directed
  • The MDI can be taken directly or with the help of
    a spacer - In case of DPI devices the hand-mouth
    coordination is not required

91
Metered Dose Inhaler
92
Metered Dose Inhaler with spacer
93
Dry Powder Inhaler (Unit Dose)
94
Dry Powder Inhaler (Multiple Unit Dose)
95
Nebulizer
John Rees. Methods of delivering drugs. BMJ 2005
331 504-506. (Reproduced with permission)
96
Comparison of MDIs with DPIs
97
Comparison of nebulizers with MDIs and DPIs
98
Appendix D Rehabilitation
99
Rehabilitation
  • Patients with moderate and severe COPD and even
    severe asthma may have restricted physical
    activity as a result of exercise de-conditioning
    and muscle wasting
  • They are prone to psychosocial alterations
    (anxiety, depression and social isolation)
  • Pulmonary rehabilitation has been shown to have
    an additive effect to medical therapy since the
    latter alone may not be sufficient to tackle
    these problems
  • Pulmonary rehabilitation aims at reducing,
    reversing and if possible, preventing some/all of
    these changes and thus increase the physical and
    emotional participation of patients in day-to-day
    activities

100
Pulmonary Rehabilitation
  • Benefits of pulmonary rehabilitation include
  • Improvement in symptoms (reduction in the
    perceived intensity of breathlessness)
  • Improvement in exercise capacityImprovement in
    health-related quality of life
  • Reduction in the frequency of hospitalizations
    and duration of hospital stay
  • Reduction in the frequency and degree of disease
    related anxiety and depression
  • Possible improvement in survival

101
Pulmonary Rehabilitation
  • The key components of pulmonary rehabilitation
    include
  • Exercise Training
  • Psychosocial intervention
  • Nutritional support
  • A pulmonary rehabilitation programme
  • Appears to benefit COPD patients at all stages
  • Is likely to be effective only if it has been
    carried out for a minimum duration of 6-8 weeks
  • The longer it continues, the more effective it is
    likely to be for the patient
  • Benefit achieved during the program can be
    sustained if its components are continued on a
    domiciliary basis

102
Exercise Training
  • Exercise training
  • Is aimed at correcting the peripheral muscle
    dysfunction (commonly seen in moderate to severe
    COPD and occasionally in severe asthma)
  • Of both upper and lower extremity muscles is
    recommended
  • Improvement in muscle strength and endurance are
    specific to only those muscles which are trained

103
Exercise Training
  • Exercise training
  • Upper extremity exercise training
  • Is necessary since many activities of daily
    living involve use of upper extremities
  • Improvement in arm function helps to reduce
    dyspnea during upper limb activities by reducing
    ventilatory requirements for arm elevation
  • Examples of upper extremity training exercises
    include use of free weights and elastic bands
  • Lower extremity training
  • Helps to improve exercise tolerance as a whole
  • Can be achieved by exercises like walking,
    jogging or cycling

104
Exercise Training
  • Exercise training
  • High intensity exercise
  • Produces greater physiologic benefits
  • Should be encouraged in an attempt to achieve
    maximal physiologic benefits that can be attained
    by exercise training.
  • Low intensity training
  • Is an alternative for patients who cannot
    tolerate or achieve high intensity exercise
    training due to severe disease, limitation by
    symptoms or comorbidities and lower motivation
    levels
  • Long term adherence is more likely with this kind
    of exercise training

105
Exercise Training
  • Exercise training
  • Respiratory muscle training especially
    inspiratory muscle training is also beneficial
    when it is used as an adjunct to general exercise
    training
  • Endurance training is the most commonly used
    modality and includes exercises like cycling or
    walking. Sessions should exceed 30 minutes with
    the exercise being performed at high intensity
  • Interval training is used in patients in whom the
    desired training time or intensity cannot be
    achieved. It is a modification of endurance
    training since it involves several small sessions
    separated by periods of rest or lower intensity
    exercise

106
Exercise Training
  • Exercise training
  • Strength (or resistance) training
  • Helps to improve muscle mass and strength much
    more than endurance training
  • Involves performance of 2-4 sets of 6-12
    repetitions of muscle exercises at an intensity
    of 50-75 of maximal effort
  • Combining endurance and strength training is
    optimal since improvements in both muscle
    strength and whole body endurance lead to better
    physiological changes. If available, a
    physiotherapist (especially a respiratory
    therapist) should be involved in the initial
    exercise training process

107
Psychosocial intervention
  • Psychosocial intervention
  • Initial assessment should be aimed at detecting
    problems like mood changes, anxiety and
    depression
  • Mild or moderate levels of anxiety or depression
    related to the disease process may improve with
    pulmonary rehabilitation and in this regard,
    services of a trained psychologist or counselor,
    if available, can prove to be helpful
  • Patients with significant psychiatric disease
    should be referred for appropriate professional
    care
  • The family members should be encouraged to help
    the patient keep a high morale despite
    physiological limitations

108
Nutritional support
  • Nutritional support
  • Nutritional guidance is essential to enable
    patients to maintain appropriate caloric and
    protein intake and thus reverse the process of
    weight loss and muscle breakdown that is often
    seen in severe COPD
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