asthma in general practice dec 2010 (1)
DESCRIPTION
AsthmaTRANSCRIPT
![Page 1: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/1.jpg)
Why asthmais goodfor your practice
Dr. Sujeet RajanRespiratory PhysicianBombay Hospital Institute of Medical Sciences
![Page 2: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/2.jpg)
Greatopportunity
Easyopportunity
![Page 3: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/3.jpg)
Asthma is so common….1 in 10 of your patients !
Most patients prefer treatment from their family doctor rather than a Chest Physician
Physicians / GPs can treat asthma just as well as Chest Physicians ( even better )
![Page 4: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/4.jpg)
The 4 keys tosuccessful asthma practice
“Is it asthma?”
Just a few questions in a few minutes
1
![Page 5: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/5.jpg)
The 4 keys tosuccessful asthma practice
Treating the disease2
Not much time
……..and easily.
![Page 6: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/6.jpg)
The 4 keys tosuccessful asthma practice
Making things simple for your patient3
Child’s play
Low cost
![Page 7: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/7.jpg)
The 4 keys tosuccessful asthma practice
Saying the right things
Answering patients’ questions
“Jo bolega, karega”
4
![Page 8: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/8.jpg)
Which secret do you want to unlock?
1. “Is it asthma?”
2. Treating the disease
3. Making things simple
4. Saying the right things
![Page 9: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/9.jpg)
Diagnosis: Why make it ?
The patient has alternatives
(if you don’t, someone else will !)
Excellent prognosis, esp. in children
Treatment is so simple
![Page 10: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/10.jpg)
Do I need a lot of tests?
Nothing usually, besides a sharp history
![Page 11: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/11.jpg)
What questions or statements can suggest asthma?
Do you have a persistent cough ?
Do you wheeze or often feel breathless while
coughing ?
Do your symptoms worsen with climate
change, or dust /other allergens ?
![Page 12: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/12.jpg)
What questions or statements … Do the symptoms get worse at
night ? Do you get chest tightness with
the cough ? Does it all start with a cold ? Do your colds often “go down” into
the chest ?
![Page 13: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/13.jpg)
What questions or statements … Do your symptoms get worse after
extremes of happiness or sadness ?
(emotional swings)
Do heavy meals or late nights worsen
your symptoms ? (GE reflux)
Are your symptoms worse at work than
at home ? (occupational asthma)
![Page 14: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/14.jpg)
What questions or statements …
Does anyone else in your family suffer from any allergies ?
Ask about:skin allergies
eczemafrequent colds
‘bronchitis’
![Page 15: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/15.jpg)
What questions or statements …
“I get relief with this medicine.”
Ask: which medicine?
(always check for bronchodilator)
![Page 16: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/16.jpg)
Diagnosis in children
Commonest cause of a persistent cough is asthma
Cough after exercise, activity, play Vomiting Failure to thrive
( poor sleep, poor growth )
![Page 17: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/17.jpg)
When do you need lung function tests ?
Spirometry ( 250 to 350 rupees )
To re-confirm the diagnosis
When in doubt
Normal Spirometry ( Challenge tests )
![Page 18: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/18.jpg)
Things the patient may not tell you …
Stigma and discrimination from a “word”
Work/school absenteeism
Marital discord
Travel & holidays ‘controlled’
![Page 19: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/19.jpg)
Other ‘advice’ the patient gets
Grandparents/neighbours/ ‘friends’ –
Inhalers ???
Steroids ???
![Page 20: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/20.jpg)
Make the diagnosis but emphasize the prognosis
Instead of asthma controlling your
patient,
the patient can control asthma
![Page 21: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/21.jpg)
Asthma therapy in India today
Completely control symptoms and
fast
Normal life
As good as abroad ( even better )
General practice and physician level
Doesn’t need Chest Physicians !
![Page 22: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/22.jpg)
Asthma Disease:Spasm and swelling
Spasm needs a reliever
Bronchodilator
Swelling needs a contoller
Anti-inflammatory
![Page 23: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/23.jpg)
Two types of drugs:
Reliever & Controller
Reliever
Bronchodilator (beta2 agonist)
Quickly relieves symptoms (within 2-3 minutes)
Not for regular use
![Page 24: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/24.jpg)
Reliever …
Inhaled
Nebulised
Oral
Most of the time
For severe attacks; administer at your clinic/hospital
Rarely needed
![Page 25: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/25.jpg)
Anti-inflammatory
Takes time to act (1-3 hours)
Long-term effect (12-24 hours)
Only for regular use
(whether well or not well)
Controller
![Page 26: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/26.jpg)
If your patient uses reliever
medication every day, or even
more than three or four times a
week, preventive medication
must be added to the treatment
plan.
GINA Workshop Report, December 1995
![Page 27: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/27.jpg)
WHAT HAPPENS WHEN YOU DON’T TREAT ASTHMA WELL
N orm al
Inflam ed(A sthm a)
P artly Treated
Fixed O bstruction(Lead P ipe)
R em odelledA irw ay
![Page 28: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/28.jpg)
What is changing the lives of our asthma patients today?
Inhaled steroid
![Page 29: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/29.jpg)
THE STORY OF ASTHMA TREATMENT
N orm al Inflam ed (untreated)
R egularInha ledS tero id
P artlyTreated
![Page 30: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/30.jpg)
Corticosteroids are the most potent and effective anti-inflammatory medication currently available
for asthma*
*GINA (NHLBI & WHO Workshop Report), December 1995
*Guidelines for the diagnosis and management of Asthma NIH, NHLBI, May 1997
![Page 31: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/31.jpg)
Controller ..
Inhaled corticosteroids Budesonide/ beclomethasone/
fluticasone/ciclesonide – use any Start (400-1000 mcg/day approx. in
2 divided doses) Maintain for 3 months Taper slowly Safe for long-term use (years)
![Page 32: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/32.jpg)
Controllers …
Inhaled corticosteroids: how safe? Even in small children for several
years 30% of Olympic athletes Not anabolic (performance-enhancing)
steroid Even highest ICS dose is safer than
low dose oral steroid Best “Addiction” for asthmatics
![Page 33: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/33.jpg)
Inhaled steroids : safe even for children? 400 mcg/day (budesonide) Over 13 years of continuous use No growth retardation Uncontrolled asthma causes growth
retardation
Pedersen & Agertoft NEJM 2000
![Page 34: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/34.jpg)
Pregnancy and asthma
Don’t x-ray (if possible) All asthma medication is safe Even oral corticosteroids are safe for
exacerbations Uncontrolled asthma during pregnancy
is a serious risk factor for foetal distress and anoxia
Thorax
![Page 35: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/35.jpg)
Inhaled Steroids Not Working ?
Add SRtheophylline
Check Inhaler Technique /
Check Regular UseAdd LABA
Formoterol / Salmeterol
Increase dose of inhaled steroid
Add Leukotriene modifier
![Page 36: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/36.jpg)
Leukotriene Modifiers Oral anti-inflammatory
Not as effective as inhaled steroid
First-line for 2 to 5 yr. olds.
All your ‘regular’ bronchodilator users.
![Page 37: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/37.jpg)
Theophylline
Sustained release for regular use
Inexpensive , but toxic
Not more than 600 mg per day usually
Weak bronchodilator, but A-I effects
![Page 38: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/38.jpg)
Add-on drugs : ICS + ?
1. Long acting Beta²-agonist ( LABA )
2. Montelukast
3. SR Theophylline
![Page 39: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/39.jpg)
ICS + LABA
Which ICS ?
Budesonide: Once daily
Even children < 4 years
Safe for long term use
![Page 40: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/40.jpg)
ICS + LABA
Which LABA ?
Formoterol: Immediate relief (as fast as salbutamol)
12 hours effect
Can be combined with budesonide
![Page 41: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/41.jpg)
Ideal combination
Formoterol ( fast relief and sustained relief ) +
Budesonide ( twice or even once daily use )
Dose: 1- 4 puffs ( OD/BD )
![Page 42: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/42.jpg)
Can be used for relief as well as control
FORACORT
![Page 43: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/43.jpg)
Guidelines for using SMART with FOACORT• SMART means patients take a daily maintenance dose of
FORACORT and in combination take FORACORT as needed in response to symptoms.
The recommended maintenance dosage is 2 inhalations per day
Patients should take 1 additional inhalation as needed in response to symptoms. If symptoms persist after a few minutes, an additional inhalation should be taken. Not more than 6 inhalations should be taken on any single occasion.
A total daily dose of up of 12 inhalations could be used for a limited period.
Patients using more than 8 inhalations daily should be strongly recommended to seek medical advice.
![Page 44: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/44.jpg)
Oral Steroid
Prednisolone Acute severe episodes
(20-60 mg/day “burst”along with bronchodilators)
Dispense preferably Steroid-dependent asthma
![Page 45: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/45.jpg)
Steroid-Dependent Asthma
A patient who requires regular
oral corticosteroids for control of
his/her asthma
![Page 46: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/46.jpg)
![Page 47: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/47.jpg)
Why doctors don’t use inhalation therapy
Status quo :“my practice is good or ‘great’”
Oral therapy is easy
Too busy
Cost
Headache to explain
![Page 48: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/48.jpg)
Which inhaler?
Inhalers
MDI DPIs Nebuliser
(acute severeepisodes only)
![Page 49: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/49.jpg)
Scope for Inhalation Therapy highest in a child
< 5 yrs - High incidence of
wheezing
Parents want the best for
their child
![Page 50: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/50.jpg)
The Rotahaler
Has transformed inhalation therapy Child’s play (Insert -Twist - Inhale) Economical (Rs. 74) Acceptable (v/s difficulties with MDI)
Every drug you need
![Page 51: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/51.jpg)
Child below 3, or adult over 85
MDI + Spacer
MDI + Spacer + Baby Mask
When can you not use a Rotahaler ?
![Page 52: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/52.jpg)
![Page 53: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/53.jpg)
Why use a Spacer ?
Ensures correct use of an MDI by correcting co-ordination problems.
Reduces incidence of throat infections with inhaled steroid
As good as nebuliser for acute exacerbations ( with MDI )
![Page 54: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/54.jpg)
Then do we need nebulisers ?
– YES
Acute severe asthma with impending respiratory failure
Intensive care / Hospital / Clinic / Ambulances
![Page 55: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/55.jpg)
Managing asthma in clinic(patient who walks in wheezing quite badly)
Oral prednisolone 20 mg/day x 1 week
Foracort Rotacaps (100/200/400) (Form +
Bud) twice daily x 1 week and also as
rescue
![Page 56: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/56.jpg)
Call patient after 1 week
If much better
Taper or omit Prednisolone
Continue Foracort Rotacaps for 2 months in same dose
Foracort Rotacaps SOS
![Page 57: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/57.jpg)
Call patient after 1 week …
If not much better /still needs salbutamol often
Check Rotahaler Technique
Check whether using Foracort regularly
![Page 58: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/58.jpg)
If still not better at 2-3 months
Consider adding SR theophylline or montelukast
Look for aggravating factors– GE Reflux– Emotions/ stress– Sinusitis– Allergic Rhinitis– Persistent allergens
![Page 59: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/59.jpg)
Always check
Inhaler technique
Regularity of steroid use
![Page 60: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/60.jpg)
What do you tell patients ?
Oh no ! I have asthma ?
Allergic disorder (allergies don’t have cures)
You could call it “allergic bronchitis”
To lead a normal life, accept regular therapy (like DM/ HT/ Epilepsy)
![Page 61: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/61.jpg)
What do you tell patients …
How long do I need this inhaler?
Wont I get addicted ?
Inhalers are a delivery system, not the drug
The drug is in a “homeopathic” dose
The earlier you start steroid, the better. ….. best “addiction”
Untreated asthma will cripple you
![Page 62: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/62.jpg)
What should you keep in your asthma clinic ? Rotahaler/ Revolizer Placebo Rotacaps Placebo MDI/ Spacer/ Baby Mask Nebuliser ( for emergencies only ) Height measure Breathe-o-meter Education material ( available in 9
languages )
![Page 63: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/63.jpg)
The Breathe-o-Meterlike a thermometer for asthma
Inexpensive clinic instrument
Monitoring Builds confidence in
treatment
One ‘hard, fast blow’
![Page 64: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/64.jpg)
The Breathe-o-Meter…
First visit and follow-ups
Improving symptoms
= improving peak flows
= improving confidence
Rarely for home use
![Page 65: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/65.jpg)
What do you tell patients …
Today’s asthmatics are suffering as
they never received regular inhaled
steroids as children.
What costs more is not better (e.g.
nebulisers for home use)
![Page 66: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/66.jpg)
Examples
Myopics Spherical glasses regularly
Everyone Brushing teeth regularly
Obesity Diet & exercise regularly
Asthmatics Inhaled steroid regularly
![Page 67: Asthma in general practice dec 2010 (1)](https://reader034.vdocuments.us/reader034/viewer/2022050808/54963fb6ac795959288b518b/html5/thumbnails/67.jpg)
Asthma management: nothing specialistabout it
Dr. Sujeet RajanRespiratory PhysicianBombay Hospital Institute of Medical Sciences