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ASTHMA AT PRIMARY
CARE LEVEL
Training Module For Health
Care Providers
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
PAGE CHAPTER I
MANAGEMENT OF ASTHMA
1 Topic 1 Management of Asthma at Primary Care level
87 Topic 6 Application of Peak Flow Meter (PFM) and Spirometry in management of asthma
CHAPTER II
CHAPTER III
ASTHMA DSA PROJECTS
111 1. Management of bronchial asthma in health clinic: outcome & remedial measures conducted
at Health Clinic Tampin since 2008
117 2. Improving QA asthma through a district specific approach - District Office Kuala Langat
133 4. Increase the implementation of Controlled Asthma among the asthmatic patient in Perlis
139 Appendix I
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
EDITORS
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
The narrowing of the airways and increase in mucus production due to these trigger factors, will reduces
the flow of air in and out of the lungs, resulting in an asthma attack. It is estimated that there are 300
million asthmatics globally. National Health Morbidity Survey 2006 showed a prevalence of adult asthma
was 4.5% and childhood asthma up till 18 years old was 7.14%. Intermittent asthma among adult was 7.2%
and persistent asthma has 25.8% while 68.1 % experience acute exacerbations of bronchial asthma.
Level of asthma control among community is still low at 32.9% in a study done in Perak from 2007 till
2009. In a 2009 study done in Selangor, 93.8% of asthmatic patients did not perform the PEF test, 62.7%
demonstrated a wrong inhaler technique and only 66.3 % patient knew the care plan for an acute asthma
attack Therefore, there is an urgent need for the management and monitoring of asthmatic patient at the
primary care level to be strengthened.
Patient’s knowledge to manage their asthma is highly dependent on patient education given to them by
the healthcare provider. In the primary care clinic the patient is handled by the primary health care team
including doctors, nurses, assistant medical officer, pharmacist and assistant pharmacist. In service training
of the primary health care team to maintain competency in managing asthma need to be conducted regularly
at the implementation level. With the development of this module the training for providers at primary care
setting will be facilitated.
During the workshop and the course, all the physicians such as Respiratory Physicians, Family Medicine
Specialist, Public Health Specialist, Pharmacist, and the paramedic shared their experiences and made
initiatives in developing this module. Good practices, innovation and learning tools in implementation of
asthma are shared in this module
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
MANAGEMENT
OF ASTHMA
AT PRIMARY
CARE LEVEL
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
Learning objective
• Definition and pathophysiology of asthma will be discussed in this chapter
• The paramedic will be able to use clinical examination, investigation and assessment tools during
triaging at the health clinic.
SLIDE 1 Outline
1. Definition
2. Pathophysiology
3. Outcome
4. Diagnosis
5. Classification
6. Management
SLIDE 2 Definition
Chronic lung heterogeneous disease characterised by recurrent/episodic/paroxysmal
breathing problems & symptoms such as;
• Breathlessness
• Wheezing
• Chest tightness
• Coughing
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
SLIDE 4 Definition
Normal Lungs Asthma Lung
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
SLIDE 6 Pathophysiology
Airway lumen
Ciliated
epithelial cells
Blood vessel
Constricted
Bronchioles
Bronchial
smooth muscle Mucous gland
SLIDE 7 Outcome
• Acute respiratory failure.
• Irreversible airflow limitation (airways remodelling).
• Troublesome symptoms night & day.
• Limitations of physical activities / activities of daily living.
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
SLIDE 10
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
SLIDE 13 Diagnosis
Diagnostic Challenges
• Cough-variant asthma
• Exercise-induced bronchoconstriction
• Children 5 years & younger
• Asthma in the elderly
• Occupational asthma
• Asthma-COPD Overlap Syndrome (ACOS)
SLIDE 14 Classification
1. Classification of asthma severity by clinical features before treatment.
2. Assessment of levels of asthma control;
• Clinical symptoms & objective measurement;
- GINA Guidelines
• Clinical symptoms & subjective perception;
- Asthma Control Test (ACT)
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
SYMPTOMS
- Symptoms is daily
- Frequent exacerbations
Severe - Frequent nocturnal asthma symptoms
Persistent - Limitations of physical activity
- FEV1 or PEF ≤ 60% predicted
- PEF or FEV1 Variability > 30 %
- Symptoms daily
- Exacerbations may affect activity and sleep
- Nocturnal symptoms more than once a week
Moderate - Daily use of inhaled short acting β2 - agonist
Persistent - FEV1 or PEF 60% - 80% predicted
- PEF or FEV1 Variability > 30%
- Symptoms more than once a week but less than once a day
Mild - Exacerbations may affect activity and sleep
Persistent - Nocturnal symptoms more than twice a month
- FEV1 or PEF ≥ 80% predicted
- PEF or FEV1 Variability < 20 – 30%
SLIDE 16 GINA Assessment of Asthma Control
1. Asthma control – two domains
• Assess symptom control over the last 4 weeks.
- Assess risk factors for poor outcomes, including low lung function.
2. Treatment issues
• Check inhaler technique and adherence.
• Ask about side-effects.
• Does the patient have a written asthma action plan?
• What are the patient’s attitudes and goals for their asthma?
3. Co-morbidities
• Think of rhino sinusitis, GERD, obesity, obstructive sleep apnoea,
depression, anxiety.
• These may contribute to symptoms and poor quality of life.
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SLIDE 18 Management
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2. Achieving these goals requires a partnership between patient and their health
care providers;
• Ask the patient about their own goals regarding their asthma.
• Good communication strategies are essential.
• Consider the health care system, medication availability, cultural and
personal preferences and health literacy.
SLIDE 21 The control based asthma management cycle
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
SLIDE 24 Initial controller treatment for adults, adolescents and children
6–11 years
1. Start controller treatment early;
– For best outcomes, initiate controller treatment as early as possible after
making the diagnosis of asthma.
2. Indications for regular low-dose ICS - any of;
– Asthma symptoms more than twice a month.
– Waking due to asthma more than once a month.
– Any asthma symptoms plus any risk factors for exacerbations.
3. Consider starting at a higher step if;
– Troublesome asthma symptoms on most days.
– Waking from asthma once or more a week, especially if any risk factors for
exacerbations.
4. If initial asthma presentation is with an exacerbation;
– Give a short course of oral steroids and start regular controller treatment
(e.g. high dose ICS or medium dose ICS/LABA, then step down).
SLIDE 25 Initial controller treatment
1. Before starting initial controller treatment;
• Record evidence for diagnosis of asthma, if possible.
• Record symptom control and risk factors, including lung function.
• Consider factors affecting choice of treatment for this patient.
• Ensure that the patient can use the inhaler correctly.
• Schedule an appointment for a follow-up visit.
2. After starting initial controller treatment;
• Review response after 2-3 months, or according to clinical urgency.
• Adjust treatment (including non-pharmacological treatments).
• Consider stepping down when asthma has been well-controlled for 3
months.
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
*For children 6-11 years, theophyline is not recommended, and preferred Step 3 is medium dose ICS.
** for patients prescribed BDP / Formoterol or BUD / formateral maintannce and reliever therapy.
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2. Other options
• Consider adding regular low dose inhaled corticosteroid (ICS) for patients
at risk of exacerbations.
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1. Preferred option: regular low dose ICS with as-needed inhaled SABA;
• Low dose ICS reduces symptoms and reduces risk of exacerbations and
asthma-related hospitalization and death.
2. Other options;
• Leukotriene receptor antagonists (LTRA) with as-needed SABA;
- Less effective than low dose ICS.
- May be used for some patients with both asthma and allergic rhinitis,
or if patient will not use ICS.
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4. Other options;
• Adults/adolescents: Increase ICS dose or add LTRA or theophylline (less
effective than ICS/LABA).
• Children 6-11 years – add LABA (similar effect as increasing ICS).
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
SLIDE 36 Low, medium and high dose inhaled corticosteroids
Children 6–11 years
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SLIDE 40 Indications for considering referral
1. Difficulty confirming the diagnosis of asthma;
• Symptoms suggesting chronic infection, cardiac disease etc.
• Diagnosis unclear even after a trial of treatment.
• Features of both asthma and COPD, if in doubt about treatment.
2. Suspected occupational asthma;
• Refer for confirmatory testing, identification of sensitizing agent, advice
about eliminating exposure, pharmacological treatment.
3. Persistent uncontrolled asthma or frequent exacerbations;
• Uncontrolled symptoms or on-going exacerbations or low FEV1 despite
correct inhaler technique and good adherence with Step 4.
• Frequent asthma-related health care visits.
4. Risk factors for asthma-related death;
• Near-fatal exacerbation in past.
• Anaphylaxis or confirmed food allergy with asthma.
5. Significant side-effects (or risk of side-effects);
• Significant systemic side-effects.
• Need for oral corticosteroids long-term or as frequent courses.
6. Symptoms suggesting complications or sub-types of asthma;
• Nasal polyposis and reactions to NSAIDS (may be aspirin exacerbated
respiratory disease).
• Chronic sputum production, fleeting shadows on CXR (may be allergic
bronchopulmonary aspergillosis).
7. Additional reasons for referral in children 6-11 years;
• Doubts about diagnosis, e.g. symptoms since birth.
• Symptoms or exacerbations remain uncontrolled.
• Suspected side-effects of treatment, e.g. growth delay.
• Asthma with confirmed food allergy.
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
2. Contributory factors;
• Unintentional (e.g. forgetfulness, cost, confusion) and/or
• Intentional (e.g. no perceived need, fear of side-effects, cultural issues,
cost).
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4. Phenotype-guided treatment;
• Sputum-guided treatment to reduce exacerbations and/or steroid dose.
• Severe allergic asthma: suggest add-on anti-IgE treatment (omalizumab).
• Aspirin-exacerbated respiratory disease: consider add-on LTRA.
5. Non-pharmacological interventions;
• Consider bronchial thermoplasty for selected patients.
• Comprehensive adherence-promoting program.
SLIDE 45 Managing exacerbations in primary care
Principals;
1. Repetitive bronchodilator with rapid-acting ß2-agonist.
2. Oxygen supplementation.
3. Systemic glucocorticosteroids.
4. According to severity of asthma exacerbations.
5. Aims;
• Prevent death from acute respiratory failure.
• Relieve airway obstruction.
• Relieve hypoxaemia.
• Restore patient’s clinical condition & lung function to normal as soon as
possible.
• Maintain optimal lung function & prevent early relapse.
• Plan avoidance of future relapse.
• Develop an action plan in case of further exacerbation.
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
SLIDE 49 Written asthma action plans
1. All patients should have a written asthma action plan;
• The aim is to show the patient how to recognize and respond to worsening
asthma.
• It should be individualized for the patient’s medications, level of asthma
control and health literacy.
• Based on symptoms and/or PEF (children: only symptoms).
2. The action plan should include;
• The patient’s usual asthma medications.
• When/how to increase reliever and controller or start OCS.
• How to access medical care if symptoms fail to respond
3. Why?
• When combined with self-monitoring and regular medical review, action
plans are highly effective in reducing asthma mortality and morbidity.
SLIDE 50 Written asthma action plans – medication options
1. Increase inhaled reliever;
• Increase frequency as needed.
• Adding spacer for pMDI may be helpful.
2. Early and rapid increase in inhaled controller;
• Up to maximum ICS of 2000mcg BDP/day or equivalent.
• Options depend on usual controller medication and type of LABA.
3. Add oral corticosteroids;
• Adults: prednisolone 1mg/kg/day up to 50mg, usually 5-7 days.
• Children: 1-2mg/kg/day up to 40mg, usually 3-5 days.
• Morning dosing preferred to reduce side-effects.
• Tapering not needed if taken for less than 2 weeks.
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SLIDE 55 Common differential diagnoses of asthma in children ≤5 years
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
2. Self-management;
• Education, inhaler skills, written asthma action plan, adherence.
3. Regular review;
• Assess response, adverse events, establish minimal effective treatment.
4. Other;
• (Where relevant): environmental control for smoke, allergens, indoor or
outdoor air pollution.
2. Other options;
• Oral bronchodilator therapy is not recommended (slower onset of action,
more side-effects).
• For children with intermittent viral-induced wheeze and no interval
symptoms, if as-needed SABA is not sufficient, consider intermittent ICS.
Because of the risk of side-effects, this should only be considered if the
physician is confident that the treatment will be used appropriately.
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
1. Indication;
• Child with symptom pattern consistent with asthma, and symptoms not
well-controlled, or ≥3 exacerbations per year.
• May also be used as a diagnostic trial for children with frequent wheezing
episodes.
2. Preferred option: regular daily low dose ICS + as-needed inhaled SABA;
• Give for ≥3 months to establish effectiveness, and review response.
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
1. Indication;
• Asthma diagnosis and symptoms not well-controlled on low dose ICS.
• First check symptoms are due to asthma, and check adherence, inhaler
technique and environmental exposures.
3. Other options;
• Consider adding LTRA to low dose ICS (based on data from older children).
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SLIDE 65 ‘Low dose’ inhaled corticosteroids (mcg/day) for children ≤5 years
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
SLIDE 69 Initial management of asthma exacerbations in children ≤5 years
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
UPDATE ON
MANAGEMENT
OF ASTHMA AND
ASSESSMENT TOOL
Learning objective
• Brief update for health care provider on asthma assessment tools, management target of asthma
treatment and control.
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SLIDE 4 Asthma and Allergic Rhinitis: 2 Related Conditions linked by 1
Common Airway
1. Frequently overlapping conditions
2. Involvement of similar tissues
3. Common inflammatory processes
• Common inflammatory cells
• Common inflammatory mediators
SLIDE 5 Poor Adherence Factors
I Unintentional non-adherence
1. Inadequate understanding of disease
2. Poor comprehension of drug regimen or inhaler technique5
3. Simple forgetfulness
4. Socioeconomic factors
II Intentional non-adherence
1. Patient’s understanding of health benefits
2. Ethnic/cultural differences
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
SLIDE 7 What does control really mean?
SLIDE 8 Using the adult ACT score (appendix 1 chapter topic 1)
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
Overall
asthma
control
Achieving Reducing
CURRENT FUTURE
CONTROL RISK
Defined Defined
by by
Loss of Adverse
Activity Lung lung effects of
function function medication
SLIDE 10 Outcome: Tampin Health Clinic 2009 – 2012
SLIDE 11 Conclusions
1. Poor asthma control worsens patient’s quality of life
2. Deaths and hospital costs reduced with improved control
3. Control can be achieved in line with guidelines, benefiting patient’s quality
of life
4. Asthma control instruments have predictive validity
5. Poor asthma control score associated with:
• Big impact on patient’s life
• Increased exacerbations, admissions and doctor visits
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
ASSESSMENT
AND MONITORING
ASTHMA AND
CLINICAL ACTION
PLAN
Learning objective
• Update on the latest GINA 2014 classification for adult and paediatric group (age below 5 years old),
asthma control test (ACT) monitoring for adult and children (4 to 11 years old), normogram for adult and
paediatric group and clinical action plan for adult and paediatric group which are the most important
tools upon discharging patient.
• All the monitoring tools are updated and can be used for the assessment, monitoring and adjusting the
medication dose for asthmatic patient. Paramedic may use these tools during triaging the patient and
it is useful in managing the asthma controlled level and also emergency cases.
SLIDE 2 Global Initiative for Asthma Management (GINA)
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
SLIDE 4 PEFR normogram: Pediatric
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Asma layout.indd 50
SLIDE 5 Clinical action plan: Adult and adolescent
SIHAT RAWATAN BERWASPADA RAWATAN BAHAYA RAWATAN
• Tidak batuk Gunakan Inhaler Bila ada salah satu tanda-tanda Ikut peraturan berikut Dapatkan rawatan Jumpa Doktor SEGERA
• Tidak sesak nafas Pencegah setiap hari. berikut : selama 7 -14 hari. dengan Segera
• Tidak sesak dada Inhaler Pencegah • Terbangun dari tidur pada waktu Jika sembuh sila • Serangan sesak Jangan tunggu
• Tiada pernafasan berbunyi ______sedutan 2 kali malam disebabkan serangan semput. kembali kepada Zon 1 nafas yang teruk Telefon ambulan 999
• Tidak terbangun pada waktu / hari. • Serangan semput lebih dari 2 kali (zon hjau). • Tidak boleh
malam kerana asma semput Z seminggu pada waktu siang. Z bercakap dengan Inhaler Pelega:
(Bacaan “peak flow” 80-100% O • Penggunaan ubat pelega lebih dari Inhaler Pelega: O lancar. 2 Sedutan setiap 10
N 2 kali seminggu. 2 sedutan SAHAJA bila N • Serangan semput minit sehingga sampai
Z • Aktiviti atau senaman terhad perlu dan 4–6 jam yang teruk dan ke hospital atau jumpa
O disebabkan serangan semput. Tanda- sekali, tidak lebih dari • menakutkan. doktor.
N K tanda selsema /demam. 12 sedutan sahaja. M • Ubat Pelega tidak
U (Bacaan “peak flow” 50-80%) E • Melegakan
H N Inhaler Pencegah ____ R • Langsung
I I sedutan 2 kali / hari A
J N H (Bacaan “peak
A G flow” kurang 50%)
U Sebelum senaman atau ada Inhaler Pelega: Jika tiada kelegaan
tanda-tanda semput ringan 2 Sedutan SAHAJA bila dengan rawatan di
perlu atas :
Jumpa Doktor
MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
asma bila bermain atau aktif __________ Z • Alami tanda -tanda batuk, Kali / hari 3 jam sekali (Inhaler Pelega):
Z • Tidak memerlukan ubat pelega Dos: _______ ketat dada dan berbunyi Ambil Inhaler Pencegah: Z Ubat: MDI
O
O lebih dari 3 kali seminggu Kekerapan di dada (Hanya jika dipreskripsi oleh doktor) O B) MERBAHAYA Salbutamol
N
N (malahan kegunaan waktu _______kali / hari • PEFR:____ L/min Nama ubat: N • Tanda-tanda di atas
bermain) _________ menjadi semakin Dos :
K
H • PEFR:___ L/min Dos: ______ M teruk ______
U
I Kekerapan: E • Masih sesak nafas 6 sedutan
N
J _________ R atau ketat dada setiap 20 minit
I
A kali / hari A walaupun selepas semasa
N
U Bila gejala asma anak anda bertambah H menggunakan ubat perjalanan ke
G
pulih, ambil semula dos sebelum ini pelega hospital
semasa sihat. • Sesak nafas semakin
teruk, tidak boleh
bercakap dan bibir
menjadi biru
• PEFR:______L/min
Sebelum senaman atau ada Jika tiada kelegaan dengan
tanda-tanda semput ringan rawatan di atas: Jumpa
Doktor
11/26/14 3:16 PM
TOPIC 4
MANAGEMENT
OF CHILDHOOD
ASTHMA
ACCORDING TO
MALAYSIA CPG
Overall
asthma
control
Pathogenesis
Management
Triggers:
• Virus Environmental
controls
• Allergens
• Irritants
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SLIDE 4 Differential diagnosis of asthma
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CHILDHOOD
WHEEZING
(50%)
Transient
early Persistent Late onset
N= 1246 wheeze wheeze wheezes
(20%) (15%) (15%)
Persistent
wheeze NO YES YES
SLIDE 6 Pattern of wheeze
Term Definition
Episodic viral wheeze Wheeze during discrete times in association with clinical
evidence of viral cold absence of wheeze between episodes
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
Intermittent Asthma
Persistent Asthma
SLIDE 8 Long term management of Persistent Asthma
INTERMITTENT
STEP 1
Intermittent 2 AGONIST
STEP 2 Mild
persistent Low dose inhaled steroids or leukotriene antagonist
asthma
STEP 3 Moderate
persistent Moderate dose of inhaled corticosteroids
asthma
STEP 4 severe
Moderate dose of inhaled corticosteroids
persistent
asthma combination / high dose inhaled corticosteroids
STEP 5 severe
persistent Add theophylline / alternate day corticosteroids
asthma
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
Well Partly
In the past 4 weeks, the child had: Uncontrolled
controlled controlled
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REDUCE
Level of Control Treatment options
Controlled Maintain and find lowest controlling step
Partially controlled Consider stepping up to gain control
INCREASE
Uncontrolled Step up until controlled
Exacerbations Treat as exacerbations
INCREASE
SLIDE 12 Long Term Follow-up
SLIDE 13 Pulmonary Function Test: Spirometry
1. At the time of initial assessment
2. After treatment initiated and stabilization of symptoms
3. To document a near normal attainment of lung function
4. When there is loss of control
5. At least yearly to document maintenance of lung function
6. More frequent if clinically indicated
SLIDE 14 Spirometry
Three basic measurements:
1. Forced Vital Capacity (FVC)
2. Forced Expiratory Volume In One Second (FEV1)
3. Ratio of FEV1/FVC (Forced Expiratory Ratio FER or FEV1 %)
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
SLIDE 16 Calculations
Bronchodilator response
1. Best pre- bronchodilator PEFR i.e. a
2. Best post-bronchodilator PEFR i.e. b
3. Calculate percentage of bronchodilator response
(b-a) x 100
=c%
a
SLIDE 16 Reliever
Relieve respiratory symptoms
1. Reliever : intermittent short acting
B2 agonist drug of choice
2. Oral bronchodilator discouraged
SLIDE 17 Preventer
1. Reduce airway inflammation inhaled
corticosteroids treatment of choice
2. Leukotrienes antagonist
3. Age of child
4. Asthma wheeze phenotypes
5. Frequency and severity of symptoms
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SLIDE 19 Inhaler devices according to age
Children aged > 6 years • Metered dose inhaler + spacer with facemask
• Metered dose inhaler + spacer with mouthpiece
• Dry powder inhaler
• Breath device (> 8 years)
SLIDE 20 Assessment of asthma exacerbations
1. History and physical examination is an important tool to assess the
severity of asthma
2. The time of onset of the exacerbation
3. To identify underlying cause of the present exacerbation such as URTI,
cigarette smoker and etc
4. Severity of symptoms including exercise and sleep disturbance
5. All current asthma medications that the patient has been on prior to the
exacerbation
6. The dose of preventer therapy taken during the deterioration
7. Patient’s response to therapy during the exacerbation such as to the dose
of bronchodilator or oral steroids taken.
8. Risks factors: Past history of hospitalizations, intensive care, ER visits
due to exacerbations
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SLIDE 22 Management based on severity
Severity Treatment Observation Plan
Mild Nebulized salbutamol or MDI Observe for 60 minutes Discharge with improved long
salbutamol + spacer (4 – 6 puffs, after last dose term treatment and asthma
< 6 yo) and 8 – 12 puffs, > 6 yo) plan
Oral prednisolone 1 mg / kg Short course of oral steroid
/ day (max: 60 mg perday for (3 – 5 days)
3 – 5 days as moderate)
Regular bronchodilator 4 – 6
hourly for few days then PRN
Early TCA 2 – 4 weeks
Review after 20 minutes, if no
improvement treat as moderate
Moderate Nebulised salbutamol ± ipratropium Observe for 60 minutes Discharge with improved long
bromide (3 at 20 minutes intervals), after last dose term treatment and asthma
oxygen at 8 liters/ min via face plan
mask and Oral prednisolone 1 mg Short course of oral steroid
/ kg / day (max: 60 mg perday for (3 – 5 days)
3 – 5 days
Regular bronchodilator 4 – 6
hourly for few days then PRN
Early TCA 2 – 4 weeks
Admit if no improvement
Severe Nebulised β2 agonist every 20 Continue observation and
/ life minutes / continous for 1 hour. review
threatening Ipratropium bromide 3x every
20 minutes
Oxygen (face mask 8 liters)
Steroids (oral / IV)
IV salbutamol cntinous infusion
1 – 5mic/kg/min ± loading
15 mic/ kg over 10 minutes
Subcutaneous β2 agonist
(terbutraline / adrenaline)
IV bolus magnesium
sulphate 50% 0.1 ml/kg (50mg/kg)
over 20 minutes
Consider HDU / ICU admission
± IV aminiphylline
± Ventilation
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
SLIDE 23 High risk of asthma group
SLIDE 24 Conclusion
1. Correct diagnosis
2. Classification of severity
3. Classification of asthma control
4. Appropriate medication
5. Recognizing high risk asthmatics
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STEPWISE
APPROACH, INHALER
TECHNIQUE AND
PHARMACOTHERAPY
IN ASTHMA
MANAGEMENT
Learning Objective
• List of controller and preventive medication are mentioned in this topic for better understanding.
Side effect of each medication is stated in this module for better practice and learning purposes.
• Adjust medication & dosage based to the level of asthma management. Learn the right technique in
using inhaler and peak flow meter with better illustrtive.
Koda-Kimble M.A., Young L.Y., Alldredge B.K., Corelli R.L., Guglielmo B.J., Kradjan
W.A. et al. (2009). Applied therapeutics: the clinical use of drugs. 9th ed.
Lippincott Williams & Wilkins. Philadelphia, Pennsylvania, USA.
CLASSIFICATION FEATURES
Mild Persistent • Symptoms more than once a week but less than once a day
• Exacerbations may affect activity and sleep
• Nocturnal symptoms more than twice a month
• FEV1 or PEF ≥ 80% predicted
• PEF or FEV1 variability < 20 – 30%
FEV1: forced expiratory volume in one second; PEF: peak expiratory flow.
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
Koda - Kimble M.A et al. (2009). Applied therapeutics: the clinical use of drugs.
9th ed. Lippincott Williams & Wilkins. Philadelphia, Pennsylvania, USA.
Stepped up and stepped down therapy using asthma medications, also known
as stepwise approach, can be done by gathering information from each
appointment with clinicians.
SLIDE 4 Asthma management
Global Initiative for Asthma (GINA): Global strategy for asthma management and
prevention updated 2010.
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
Drug Low daily Medium daily dose (µg) High daily dose (µg)++
dose (µg)
Notes
• The most important determinant of appropriate dosing is the clinician’s judgement of the
patient’s response to therapy. The clinician must monitor the patient’s response in terms of
clinical control and adjust the dose accordingly. Once control of asthma is achieved, the dose
of medication should be carefully titrated to the minimum dose required to maintain control,
thus reducing the potential for adverse effects.
• Designation of low, medium and high doses is provided from manufacturers’ recommendations
where possible. Clear demonstration of dose-response relationships is seldom provided or
available. The principle is therefore to establish the minimum effective controlling dose in
each patient, as higher doses may not be more effective and are likely to be associated with
greater potential for adverse events.
• As CFC preparations are taken from the market, medication inserts for HPA preparations
should be carefully reviewed by the clinician for the equivalent correct dosage.
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
National Heart, Lung, and Blood Institute, National Asthma Education and Prevention
Program, Expert Panel Report 3. (October 2007). Guidelines for the Diagnosis and
Management of Asthma. US Department of Health and Human Services. NIH Publication
No. 08-5846.
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
Bronchial Asthma
• Airway inflammation
• Episodic, reversible bronchospasm
• Chronic inflammation that leads to marked bronchial hyper - reactivity or
hypersensitivity (cornerstone: inhaled corticosteroid, ICS)
• Exposure to allergen or trigger factors (extrinsic or intrinsic factors) →
stimulate a broncho - constrictive response
- Humidity, temperature changes, smoke, fumes, stress, emotional upset,
allergies, dust, food, some drugs
• Release of several mediators from IgE-sensitized mast cells and other cells
involved in immunologic responses
• Mast cells stimulate release of chemical mediators (histamines, cytokines,
serotonin, ECF-A (eosinophils))
• These chemical mediators stimulate:
- bronchial constriction
- mucous secretions
- inflammation
- pulmonary congestion
SLIDE 8 Goal Of Therapy : Control Of Asthma
Reduce impairment
• Require infrequent use (< 2 days a week) of inhaled SABA for quick relief of
symptoms (not including prevention of exercise-induced bronchospasm [EIB])
• Maintain normal activity levels (including exercise and other physical activity and
attendance at school or work)
• Meet patients’ and families’ expectations of and satisfaction with asthma care
Reduce risk
• Prevent recurrent exacerbations of asthma and minimize the need for emergency
department visits or hospitalisations
• Prevent loss of lung function; for children, prevent reduced lung growth
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National Heart, Lung, and Blood Institute, National Asthma Education and Prevention
Program, Expert Panel Report 3. (October 2007). Guidelines for the Diagnosis
and Management of Asthma. US Department of Health and Human Services. NIH
Publication No. 08-5846.
SLIDE 10 Previously GINA classified three major classes for asthma treatment:
1. ß-agonist such as salbutamol, salmeterol or terbutaline;
2. glucocorticoids such as beclomethasone ; and
3. (3) inhibitors of the cysteinyl-leukotriene (cLI) pathway such as montelukast,
zafirlukast or zileuton.
Global Initiative for Asthma (GINA): Global strategy for asthma management and
prevention updated 2009. (2009).
1. Reliever drugs [short acting ß-agonist (SABA) such as salbutamol] are
delivered as inhalers and are usually adequate for mild intermittent asthma.
2. SABA is used because it can provide rapid ‘rescue’ for acute airway
obstruction
3. ICS, long acting ß-agonist (LABA) and cLI were classified as controller drugs
in addition to rescue medication and it is necessary for mild, moderate or
severe persistent asthma.
4. This is because the controller drugs would modify the airway environment;
hence reducing the number of acute airway narrowing in the more
symptomatic patients.
Silverman, E. S., Liggett, S. B., Gelfand, E. W., Rosenwasser, L. J., Baron, R. M., Bolk,
S. et al. (2001). The pharmacogenetics of asthma: a candidate gene approach.
The Pharmacogenomics Journal, 1, 27-37.
SLIDE 11 Controller medications
1. Keeps swelling and mucus from developing in the airways
2. Must be taken EVERY day even when not having symptoms
3. Inhaled corticosteroids (ICS’s) are the most common and effective way to
control asthma
4. Help prevent asthma exacerbations from developing.
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Remember
1. Steroids are meant to work over a period of time to reduce swelling of the
airways.
2. They must be used regularly to be effective.
Always take steroids exactly as your doctor directs, even when you feel better
or do not believe they are helping you. If you stop taking steroids, your breathing
can get worse, sometimes much worse.
SLIDE 13 Possible Side Effects
SLIDE 14 Leukotrine Receptor Antagonists & Synthesis Inhibitors
1. Montelukast sodium (Singulair); Zafirlukast (Accolate)
2. Action - Decreases the inflammatory process
3. Use - prophylactic & maintenance drug therapy for asthma
4. Montelukast:
• New Leukotriene Receptor Antagonist
• Short T1/2 (2.5-5.5hours)
• Safe For Children Under 6 Years Old.
5. Leukotriene (LT) a chemical mediator that can cause inflammatory changes
in the lung.
• The group cysteinyl leukotrienes promote and increase in eosinophil
migration, mucus production, and airway wall edema, which result in
bronchoconstriction.
6. LT receptor antagonists & LT synthesis inhibitors (Leukotriene modifiers)
effective in reducing the inflammatory symptoms of asthma triggered by
allergic & environmental stimuli - Not for acute asthma
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SLIDE 17 Adrenergic Bronchodilators
1. The most effective bronchodilators
2. Mechanism of action (MOA):
• Alpha receptor stimulation which causes vasoconstriction and
vasopressor effect
• Beta-1 receptor stimulation causes increases heart rate (HR) and
myocardial contractility
• β2-adrenergic receptor stimulate adenyl cyclase and increasing
cyclic adenosine monophosphate (cAMP) in smooth muscle cells
bronchodilatation (muscle relax)
3. Almost given exclusively by inhalation:
• Decreases the systemic dose and adverse effects
• Occasionally by nebuliser
4. Aerosol administration:
• Enhances bronchoselectivity
• Provides a more rapid response
• Greater protection againts provocations that induce bronchospasm
(e.g. exercise, allergen challenges) than does systemic administration
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Salbutamol
1. As a β2-agonist, salbutamol also finds use in obstetrics.
2. Intravenous (IV) salbutamol can be used to relax the uterine smooth muscle to delay
premature labor (5mg/5ml).
3. It’s role has largely been replaced by the calcium-channel blocker (nifedipine), which
is more effective, better tolerated and orally administered.
4. Diet and body building use:
• Salbutamol is taken by some people as an alternative to clenbuterol for purposes
of fat burning and/or as a performance enhancer.
5. Detection of use
• Salbutamol may be quantified in blood or plasma to confirm a diagnosis of
poisoning in hospitalised patients or to aid in a forensic investigation.
• Urinary salbutamol concentrations are frequently measured in competitive
sports programs, for which a level in excess of 1000μg/L is considered to
represent abuse.
• The window of detection for urine testing is on the order of just 24 hours, given
the relatively short elimination half-life of the drug.
6. Doping
• Clinical studies show no compelling evidence that salbutamol and other β2-
agonists can increase performance in healthy athletes.
• In spite of this, salbutamol required “a declaration of use in accordance with the
International Standard for Therapeutic Use Exemptions” under the 2010 WADA
prohibited list.
• This requirement was relaxed when the 2011 list was published to permit the
use of “salbutamol (maximum 1600 micrograms over 24 hours) and salmeterol
when taken by inhalation in accordance with the manufacturers’ recommended
therapeutic regimen“.
• According to two small and limited studies, performed on eight and 16 subjects,
respectively, salbutamol increases the performance even for a person without
asthma.
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Formeterol
• DPI 4.5 mcg / puff: 1 - 4 puffs BD (max: 8 puffs /day)
• Symbicort turbuhaler (160/4.5 mcg)/puff
• Last for 12 hours
Toxicity
• Skeletal muscle tremor
• Significant β1 effects (tachycardia) at high clinical dosage
• Arrhythmias may occur when used excessively
• Tolerance, tachyphylaxis (loss of responsiveness) is an unwanted effect
Adverse effects
1. Common side effects :
• Tremor (20%), nervousness (15% in 2 - 6 years old), insomnia (11% in
6 - 12 years old receiving 4 - 12mg BD, headache (4 - 7%), palpitations
and tachycardia
SLIDE 20 Assessment Of Bronchodilator Therapy
1. General assessment:
• Monitoring vital signs (RR, PR, breath sounds)
2. Specific :
• Monitor PEFR
• ABG or SpO2 in acute state
• K+ and blood glucose
• If on long term – monitor PFT
• Action plan for asthma patients
• Patient education
• Correct technique of aerosol delivery
• Cleaning of aerosol device
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
airway relaxation
SLIDE 22 Ipratropium bromide
1. Quaternary antimuscarinic drug
2. Delivered directly to the airways by pressurized aerosol (MDI)
3. Minimally absorbed (systemic effects are small)
4. In excessive dosage, minor atropine-like toxic effects may occur
5. Does not cause tremor or arrhythmias
6. Need to teach clients how to use properly:
• If using ipratropium bromide with a beta-agonist (SABA), use beta-
agonist 5 mins. before ipratropium bromide
• If using ipratropium bromide with an inhaled steroid or cromolyn,
use ipratropium bromide 5 mins. before the steroid or cromolyn -
bronchioles dilate & drugs more effective
7. Example:
• Neb 0.5mg*/2.5mg → 1 - 2 unit doses (1/1 TDS - QID)
• Neb 0.0125% (125mcg/ml) → 100 - 500mcg up to 3X/d
→ adult: up to 4X/d
• MDI (20mcg*/50mcg)/puff → 1 - 2 puff qid (Max: 8 puff/d)
8. Adverse effect
Common
• Cough (5.9%) and dry mouth (2.4% - MDI; 16% -DPI: gargle the mouth)
• Occasional ( ):
• Bronchitis (10 - 23%), dizziness (2.4%), headache (2.4%), <1%
(nervousness, irritation, palpitation)
Occasional
• Bronchitis (10 - 23%), dizziness (2.4%), headache (2.4%), <1%
(nervousness, irritation, palpitation)
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Clearance varies
1. Highest in young adolescents
2. Higher in smokers
3. Concurrent use (drug-drug interaction) of other drugs that inhibit or induce hepatic
enzyme (eliminated by cytochrome P450-drug metabolizing enzyme in the liver):
• Reductions in clearance (half life & effects of theophylline): cimetidine,
erythromycin, claritromycin, allopurinol, propanolol, ciprofloxacin, ticlopidine
ects
• Enhance in clearance (effects of theophylline): rifampin, carbamazepine,
phenytoin, phenobarbital, charcoal-broiled meat & cigarette smoking
a. Theophylline and beta-adrenergic agonist given together - synergistic
effect can occur→cardiac dysrhythmias.
b. Due to large interpatient variability in theophylline clearance, routine
monitoring of serum theophylline concentrations (TDM) is esssential for
safe and effective use.
c. A steady-state range: 5 – 15mcg/ml (most patients).
d. Common adverse effects:
• GI distress (it may promote acid reflux, also known as GERD, by relaxing the
lower esophageal sphincter muscle)
• Tremor
• Insomnia
4. Others:
• Anorexia, nervousness, dizzines, palpitations, restlessness, flushing
5. Overdosage
• Severe nausea and vomiting
• Hypotension
• Cardiac tachyarrhythmias
• Convulsion/seizures
C/I: severe cardiac dysrhythmias, hyperthyroidism, peptic ulcer disease (increases
gastric secretions)
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STEP 1:
Remove the mouthpiece cover.
STEP 2:
Hold the inhaler in an upright position as shown in
diagram.
STEP 3:
Shake the MDI 3 - 5 times in an
up -down motion before each
puff to mix the contents of the
canister.
STEP 4:
Exhale slowly and completely through your mouth
before holding your breath.
DO NOT exhales into the mouthpiece.
STEP 5:
• Device should be held at an upright position.
• Insert into mouth with the head slightly tilted.
• DO NOT bites the mouthpiece.
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2 STEP 6:
Begin inhaling slowly through the mouth (1)
and simultaneously actuate the MDI ONCE (2).
3 1
Continue inhalation for about 3-5 seconds until
the lungs are full (3).
STEP 7:
Hold breath for 4 -10 seconds and leave the inhaler
in the mouth while holding breath.
1
STEP 8:
Remove inhaler (1) from mouth and exhale slowly
2
(2).
STEP 9:
Wait 30 seconds to 1 minute before repeating step
3 - 8 if subsequent doses are required.
STEP 10:
Close cap and keep the inhaler in a dry place.
NOTE:
• Patients should be advised to gargle with water after using certain types of MDIs e.g. Inhaled
Corticosteroids (ICS).
• If on two types of inhalers (steroid & bronchodilator), it is recommended to use the bronchodilator
first and wait for 5 minutes before using the steroid.
MAINTENANCE:
• Clean the plastic mouthpiece only, not the metal canister.
• Clean it with tap water at least once a week.
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STEP 1: STEP 6:
STEP 7:
STEP 2:
Wait 30 seconds to 1
Attach the large end minute before repeating
of the BI tube to the step 3 - 6 if subsequent
mouthpiece of the doses are required.
MDI.
STEP 8:
STEP 3:
After use, remove the
Shake the MDI 5 times BI Tube and replace the
in an up -down motion mouthpiece cover on the
(as shown in diagram) MDI.
before use.
STEP 4:
• Exhale slowly and
completely through
the mouth before
holding the breath.
• DO NOT exhales
into the BI tube.
STEP 5:
Press the base of the
canister (1) and inhale
the nebulizer aerosol
(2).
MAINTENANCE:
• Wash the BI tube at least ONCE A MONTH with tap water and air dry.
• Do not wipe the BI tube dry after washing.
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STEP 1: STEP 5:
Visually check for Apply mask to face
foreign objects before and ensure that there
each use. is a good seal.
STEP 6:
STEP 2:
• Press MDI ONCE at
Remove the
beginning of normal
mouthpiece cover
breath.
from the MDI.
• Breathe normally
between 5 - 10
breaths while
holding the mask
firmly to your face.
STEP 3: STEP 7:
Insert the MDI into Slow down inhalation
the adaptor of the if the WHISTLE sound
chamber. is heard.
STEP 4: STEP 8:
While holding the Wait 30 seconds
chamber with MDI to 1 minute before
firmly, shake the MDI repeating step 4 - 6 if
for 5 times in an up- subsequent doses are
down motion (as in required.
diagram).
MAINTENANCE:
• It is recommended to clean ONCE A WEEK.
• Cleaning of the product varies between the different variants of the AeroChamber®. Please refer
to each individual product information
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STEP 1: STEP 4:
STEP 5:
STEP 2:
• Simultaneously press
Remove the cap the MDI ONCE (1) at
from the MDI and the the beginning of a slow
mouthpiece cover of and deep inhalation
the chamber. (2).
• Hold breath as long as
possible, between to
4-10 seconds before
breathing out through
the nose.
STEP 6:
Slow down inhalation if a
WHISTLE sound is heard.
STEP 3:
2 • Insert the MDI into
the adaptor of the
mouthpiece (1).
• While holding the STEP 7:
1 mouthpiece with
Wait 30 seconds to 1
• MDI firmly, shake minute before repeating
the unit for 5 times step 3 - 6 if subsequent
in an up-down doses are required.
motion as shown in
diagram (2).
MAINTENANCE:
• It is recommended to clean ONCE A WEEK.
• Cleaning of the product varies between the different variants of the AeroChamber®. Please refer to
each individual product information leaflet.
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STEP 1: STEP 4:
• Hold the outer case • Put the mouthpiece
in one hand and into the mouth and
put the thumb of ensure a good seal.
the other hand on
• Breathe in forcefully
the thumb grip to
and deeply through
open the Seretide®
the mouth only.
Accuhaler®.
• Push the thumb
grip as far as it will STEP 5:
go until a “CLICK”
Remove the
sound is heard.
Accuhaler® from
the mouth and hold
STEP 2: breath for 10 seconds
or as long as possible.
• Hold the device
horizontally with
the mouthpiece
towards the
patient. STEP 6:
• Slide the lever as • Close the device by
far as it will go as sliding the thumb
in diagram until grip back to its
another “CLICK” original position
sound is heard to until a “CLICK”
load a dose in the sound is heard.
device.
• The lever will
return to its original
position and will be
STEP 3:
reset.
• Hold the Accuhaler®
away from mouth
and breathe out STEP 7:
completely.
• Repeat step 1 - 6 if
more than one dose
is required.
• Close cap and keep
the inhaler in a dry
place.
NOTE:
• Patients should be advised to gargle with water after using the Seretide®Accuhaler®.
• Number 5 to 1 appear RED to warn that there are only a few doses left.
MAINTENANCE:
• Wipe the mouthpiece of the Seretide® Accuhaler® with a dry cloth or tissue to clean it.
• The Accuhaler® is recommended to be cleaned at least ONCE A WEEK.
• The content of the device is susceptible to moisture. For this reason keep it in a dry place away
from humidity.
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STEP 1:
Unscrew and lift off the cover.
STEP 2:
• Hold the Turbuhaler® upright with the grip facing
downwards.
• Turn the grip as far as it will go (1) and then turn it
1
back as far as it will go in the opposite direction (2)
until a “CLICK” sound is heard.
• Perform this procedure TWICE.
B. Used Turbuhaler
STEP 1:
Unscrew and lift off the cover.
STEP 2:
• Hold the Turbuhaler® upright with the grip facing
downwards.
• DO NOT holds the mouthpiece when turning the
grip.
STEP 3:
To load the Turbuhaler® with a dose, turn the grip
as far as it will go in one direction as shown in the
diagram.
STEP 4:
Then turn it back again as far as it will go in the
opposite direction until a “CLICK” sound is heard.
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STEP 6:
• Place the mouthpiece gently between the lips.
• Ensure a tight seal around it as in diagram.
STEP 7:
Breathe in forcefully and deeply through the mouth
only.
STEP 8:
• Remove the Turbuhaler® from the mouth before
breathing out again.
• DO NOT breathes into the mouthpiece.
2
8
3
STEP 9:
7 Repeat step 2 - 8 if more than one dose is required.
4
6 5
STEP 10:
Replace the cover and store Turbuhaler® in a dry
place.
NOTE:
• Patients should be advised to gargle with water after using steroid containing Turbuhalers®.
• If on two types of Turbuhalers® (steroid & bronchodilator), it is recommended to use the
bronchodilator first and wait for 5 minutes before using the steroid.
2
• Turbuhaler® has a dose indicator that shows how many doses are left in the inhaler. It moves
slowly when each time a dose is loaded. When the red colour first appears in dose indicator, it
6
shows that there are only320 doses left.
MAINTENANCE:
• Clean the outside of the mouthpiece once a week with a dry cloth or tissue.
• Never use
5 water or any other
4 fluid when cleaning the mouthpiece.
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STEP 1:
Remove the powder inhaler from the laminated
pouch.
Protective cover
STEP 2:
• Insert the powder inhaler into the
protective cover.
• The dust cap on the mouth piece prevents
Dust Cap
accidental actuation of the inhaler when
inserting it into the protective cover.
STEP 1:
Remove the dust cap.
STEP 2:
• Shake the device prior to each dose.
• After shaking, hold the device in the upright
position.
“CLICK”
STEP 3:
• Press the device only ONCE between the
thumb and forefinger until a “CLICK” sound
is heard.
• Keep holding the device in the upright
position.
STEP 4:
Breathe out normally, away from the
mouthpiece.
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MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers
27 cont STEP 5:
3
STEP 6:
Remove the inhaler from mouth and hold breath
for 5 - 10 seconds.
2
STEP 7:
6 3
Repeat step 2 - 6 if more than one dose is
required.
5 4
STEP 8:
• Put the dust cap back on the mouthpiece.
• Store Easyhaler® in a dry place.
NOTE:
• Patients should be advised to gargle with water after using steroid containing
Easyhalers®.
• If on two types of Easyhalers® (steroid & bronchodilator), it is recommended to use
the bronchodilator first and wait for 5 minutes before using the steroid.
• Easyhaler® has a dose counter which indicates the number of remaining doses. The
counter turns after every five actuations. When the counter turns red there are 20
doses left.
MAINTENANCE:
• The mouthpiece can be cleaned with a dry cloth or tissue. Never use water or any
other fluid when cleaning the mouthpiece.
• Inhalation powder should not be exposed to humidity. If the powder becomes damp,
it is not suitable for use and should be disposed of.
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APPLICATION OF
PEAK FLOW METER
AND SPIROMETRY
IN MANAGEMENT
OF ASTHMA
Learning Objective
• Spirometry and peak flow meter are the most important tools in monitoring the control level of the
asthmatic.
• Peak flow meter is the common instrument that is use at the primary care setting.
• Able to use peakflow meter and analyze the reading
• Spirometry reading scale is more accurate compare to peak flow meter in diagnosing a patient lung
capacity. The pro and cons of the instrument is mentioned at the end of the topic.
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Diurnal variability of peak expiratory low rate (PEFR) greater than 20% for at
least three days in a week for two weeks is typical of asthma
Or improvements in PEF
1. 10 minutes after high dose bronchodilator through a spacer (60 liters
change)
2. After six weeks courses of inhaled steroids
3. After 14 days of 30 mg prednisolone
4. Assessment of the response to treatment
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SLIDE 6 As part of asthma action plan
1. Provide to all patients a written AAP based on signs and symptoms and /
or PEF
• Written AAP are particularly recommended for patients who have
moderate or severe persistent asthma, a history of severe excerbations
or poorly controlled asthma
2. Whether PF monitoring, symptom monitoring (available data show similar
benefits for each) or a combo of approaches is use, self monitoring is
important to the effective self management of asthma.
SLIDE 7 Do I need spirometry to make the diagnosis of asthma – YES
• History and physical are not reliable means of excluding other diagnoses,
or of characterising the status of lung impairment
• Pulmonary function reports do not reliably correlate with symptoms, and
the two together are needed for disease classification
• Peak flows are considered too variable to be accurate for diagnosis. They
are more appropriately used for disease monitoring
• Children over 5 are usually able to participate
NAEPP guideline section 3. 2007
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SLIDE 9 Spirometry: Suitable for resource limited facility
1. Inexpensive and user friendly, spirometers are now readily available for
office use
2. Much more reliable and relatively simple to incorporate into a routine
office visit
3. Modern office spirometers are portable, process numeric results
automatically and print out pre and post report
4. Accurate results accurate equipment
SLIDE 10 Importance of spirometry
1. Provides objective measure of lung function
2. Establishes airflow obstruction and REVERSIBILITY!
3. Assists in asthma diagnosis and treatment
4. Assists in determining asthma severity and asthma control
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SLIDE 12 Objective measurement
• Abnormalities of lung function are categorised as obstructive or restrictive
defects
• A reduced ratio of FEV1 / FVC as compared to the predicted value, indicates
obstruction to the flow of air to the lungs
• A reduced FVC with a normal FEV1 / FVC ratio suggest a restrictvie pattern
SLIDE 13 Spirometry results
• Airflow obstruction is indicated by reduced FEV1 and FEV1 / FVC values
relative to reference or predicted value
• The predicted depend on the individual’s age gender, height and race
• The numbers are presented as percentages of the average expected
in someone of the same age, height, sex and race. This is called percent
predicted.
SLIDE 14 Interpreting spirometry
• Normal values for FEV1 and FVC are expressed in both absolute numbers
and percent predicted of normal
• Values for FVC and FEV1 that are above 80% of predicted are defined as
within the normal range
• FEV1 / FVC ration declines as a normal part of ageing
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SLIDE 16 • Obstructive lung disease changes the appearance of the flow volume
curve
• As with a normal curve there is a rapid peak expiratory flow, but the curve
descends more quickly than normal and takes on a concave shape
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The shape of the flow volume loop is relatively unaffected in restrictive disease,
but the overall size of the curve will appear smaller when compared to normals
on the same scale.
SLIDE 18 Reliability of spirometry
1. Correct technique, caliberation methods and maintenance of equipmemy
are necessary to achieve consistently accurate test results
2. Calibration must be performed daily
3. Maximal patient effort in performing the test is required to avoid important
error in diagnosis and management (reproducibility)
4. Spirometry is an effort – depedent manoeuvre that requires understanding,
coordination and cooperation by the patient – subject who must be
carefully instructed
5. Technicians must be trained and must maintain a high level of proficiency
to assure optimal results
6. Spirometry should be performed using equipment and techniques that
meet standards developed by the American Thoracic Society
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NAEPP guidelines
SLIDE 20 Spirometry may be done more frequently
Depending on clinical severity, spirometry is also useful
• As a periodic check on the accuracy of the peak flow meter
• When more precision is desired to evaluate response to therapy
• When peak flow results are unreliable
SLIDE 21 As part of asthma action plan (AAP)
• Provide to all patients a written AAP based on signs and symtoms and / or
PEF
– Written AAPs are particularly recommended for patients who
have moderate or severe persistent asthma, a history of severe
exacerbations or poorly controlled asthma
• Whether PF monitoring, symptoms monitoring (available data show similar
benefits for each), or a combo of approaches is used, self monitoring is
important to the effective self management of asthma.
SLIDE 22 Conclusion
• Both spirometry and peak flow play important role in the management of
asthma
• Spirometry would be able to diagnose asthma objectively
• Objective monitoring can be achieve by using peak flow especially in
moderate to severe asthma
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HOW TO INTERPRET
SPIROMETRY
RESULT
Learning objective
• Peak expiratory flow rate and spirometry are important in assessing the level of asthma diagnosis
and management. Therefore the interpretation of the results must be accurate. There are a few of
Spirometry graph shown in this topic for discussion
SLIDE 1 Outline
1. ATS guidelines
2. Clinical data review
3. Volume-time curve
4. Flow-volume curve
5. Spirometry
6. Reaching a conclusion
7. Cases
ATS Guideline
SLIDE 2
Within manoeuvre criteria
I. Individual spirograms are “ acceptable “ if
a. They are free from artefacts:
• Cough during the first second of exhalation
• Glottis closure that influences the measurement
• Early termination or cut off
• Effort that is not maximal throughout
• Leak
• Obstructed mouth piece
b. They have a good starts
• Extrapolated volume < 5% of FVC or 0.15 litres whichever is greater
c. They show satisfactory exhalation
• Duration of ≥ 6 seconds (3 seconds for children) or a plateau in the
volume time curve or if the subject cannot or should not continue to
exhale
II. Between manoeuvre criteria
a. After three acceptable spirograms have been obtained, apply the
following tests:
• The two targets values of FVC must be within 0.150 L of each other
• The two largest values of FEV1 must be within 0.150 L of each other
b. If both of these criteria are met, the test session may be concluded
c. If both of these criteria are not met, continue testing until
• Both of the criteria are met with analysis of additional acceptable
spirograms or
• A total of eight tests have been performed (optional) or
• The patient / subject cannot or should not continue
d. Save as a minimum, the three satisfactory manoeuvres.
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SLIDE 4 Components of the curve
• FVC: height of the curve (Figure 2)
• FEV1: volume corresponding to 1 sec (Figure 3)
• FEF25,50,75,25-75: extracted from curve’s (Figure 4)
Slope
Figure 2 Figure 3
Figure 4
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SLIDE 6 Examine the components of the curve
• Height (PEF) and slope (FEF25-75): low – suggestive of obstructive
disorder
• Width (FVC): smaller than predicted curve, suggest restrictive (mainly) or
obstructive (less)
• 1st second mark (FEV1): estimate FEV1/FVC – low suggest obstructive
SLIDE 7 Examine the post bronchodilator curve
1. Examine the size, shape and location, compared to pre - bronchodilator
2. If the is improvement, it might indicate response to bronchodilator
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SLIDE 9 Examine FEF25,50, 75, 25-75
1. If low may suggest obstruction
2. May also be low in restrictive disorder and upper airway obstruction
SLIDE 10 Special situations
• Isolated low MMEF OR FEF indicates airflow limitation at low lung volume
• Isolated significant response to bronchodilator with normal baseline
suggest asthma
SLIDE 11 Reaching A Conclusion’
Obstructive disorder:
1. You will need then to differentiate between the two major
2. Obstructive disorders – asthma and emphysema:
• FV curve: a “dog-leg” appearance is characteristic for emphysema.
• Spirometry: a significant bronchodilator response is suggestive of
asthma.
3. Remember that other obstructive disorders (such as bronchiectasis,
obstructive bronchiolitis, and chronic bronchitis) could be responsible.
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SLIDE 13 The following helps for the distinction
FV curve:
1. A small curve with a steep slope suggests a parenchymal restriction.
2. A small curve with a parallel slope to the unpredicted curve suggests a
chest wall restriction other than NMD.
3. A convex curve suggests NMD or poor effort study.
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QAP ASTHMA
“APPROPRIATE
MANAGEMENT
OF ASTHMA”
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SLIDE 4 QAP Indicator - Appropriate Management of Asthma
1. Indicator
• % of Asthmatic cases that received appropriate treatment of Asthma
(6/6)
2. Purpose of indicator
• Monitor appropriateness of Asthma treatment by PHC personnel
Resulting quality performance hence reduce number of asthmatic
attack and morbidity
3. Advantages of indicator
• Status of Asthma treatment
• Present Asthma treatment is adequate and effective
• Indicates areas to be strengthen for Asthma treatment
• Ensure use of CPG on Asthma treatment
SLIDE 5 QAP Indicator - Appropriate Management of Asthma
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SLIDE 7 Definitions
1. Asthma
• Condition characterised by airway inflammation due to airway hyper
responsiveness, presenting with episodic or chronic wheeze and/or
cough
2. Asthmatic case
• Patient being diagnosed to suffer from BA by MO / trained personnel.
The diagnosis should be reviewed & confirmed by FMS / M&HO once
before inclusion into the study to ensure correct diagnosis
3. App. treatment of asthma
• Accepted if the asthmatic case of the HC received care as being
recommended or following the MOGC for treatment of asthma
SLIDE 8 Criteria for Appropriate treatment of Asthma
1. On recommended drugs i.e inhalers
2. PHC personnel using the app. monitoring tools i.e ACT & Levels of Asthma
Control (GINA)
3. Client well informed:
• About symptom of asthmatic attack and has his / her plan of action
• When and where to seek medications
4. Client knows:
• When to use inhalers
• How to use inhaler correctly
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SLIDE 10 Methodology (Baseline And Annual Evaluation)
1. Type of study
• Cross sectional analysis of the management of patients with Asthma
2. Sampling frame
• All asthmatic patients on follow up
3. Sample size
• 10 or 30% (not > 100)
4. Sampling method
• Random sampling from Asthma patient’s register
5. Exclusion criteria
• Mild asthmatic, Severely ill, In emergency, Children (<12 yrs)
• Communication problem
SLIDE 11 Methodology (Baseline And Annual Evaluation)
Data collection
1. Interview
a.
Trained paramedic (preferably from other clinic)
b.
Using questionnaires
c.
Time of interview
• Any clinic day at any time of the day.
• Take a few days to weeks, depending on how soon the expected
number of samples is reached.
• Periods to be avoided
- Rainy seasons
- School holidays
- Post-public holidays
2. Patient’s record
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II Limitations of Indicator
• Asthma control is highly dependent on patient’s compliance
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Performance Analysis
• Main monitoring tool at the district, state and national level is the Indicator
Chart
- Drawn up by year to compare the present performance with the
previous year(s).
• Trend of median ‘percentage of appropriate management of Asthma in the
health clinics’ is the main concern.
SLIDE 14 QAP Indicator Appropriate Management of Asthma
Quality status
The status of quality for clinic/district/state in a specific year is determined by
comparing the percentage of respondent who gets 6/6 with the median value
of previous year
SLIDE 15 QAP Indicator Appropriate Management of Asthma
Remedial Measures
Using the evaluation, strengths and weaknesses identified to facilitate drawing
up of remedial interventions activities:
• Training on MOGC
• Adequate supply of instruments and drugs
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MANAGEMENT
OF BRONCHIAL
ASTHMA IN HEALTH
CLINIC: OUTCOME &
REMEDIAL MEASURES
CONDUCTED AT
HEALTH CLINIC TAMPIN
SINCE 2008
SLIDE 1 Background
• FMS in Tampin Health Clinic involved in development of national asthma QA
in 2002/2003
• Started to implement in Tampin HC in 2004
• All asthma patient registered in asthma registration book
• 2004: FMS invent initial clerking sheet for asthma
• Using ordinary OPD card
• Medical officers reminded to manage asthma appropriately from time to
time
COUNTER
DOCTOR’S ROOM
IN COMMON POOL
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PHARMACY
Asma layout.indd 112 11/26/14 3:16 PM
SLIDE 2 Asthma card documentation : 2003-2008
• Ordinary OPD card (yellow card)
• Guided clerking sheet for first time evaluation
• A 4 size asthma diary
• Registration book
SLIDE 3 Problem identified
• Good progress during initial years but later dropped badly
SLIDE 4
Problem statement
Inability to sustain good quality of care for patients with asthma in Tampin
Health Clinic
SLIDE 5 Why?
SYSTEM
STAFF PATIENT
INABILITY TO
SUSTAIN
GOOD CARE
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SLIDE 7 Problem: System factor
• Not staff friendly
• Difficult to sustain performance
• Too dependent on trained staff
• “ Pahat & penukul “
SLIDE 8 Problem: Patient factor
• Just want to come to clinic during asthmatic attack : most of the patient
come at night
• Forgotten to chart or bring to clinic / lost the given asthma diary
• Want quick fix : short acting oral bronchodilator still preferred, not comply
to steroid MDI
SLIDE 9 Intervention: Staff
• Education about asthma
• Regular supervision by FMS
• Provide tool to make them remember easily; quick guide at outer inner
of patient’s folder, guided clerking sheet in line with requirements for
appropriate management of asthma
• Designated staff in NCD service to help them more focus ( but they do
cover other sites too: multitask, integrated yet specialized)
• Try to stick to same staff for data entry or to ensure staff trained first
before enter data
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SLIDE 11 Intervention: patient
• Appointment system
• Home based card with diary, appointment date and general info about
asthma, asthma action plan
COUNTER
THEN MO
SLIDE 12 6 important questions
1. Client is on the recommended drug
2. Public Health Care personnel is using appropriate monitoring tools,
3. Client is well informed about symptoms of an asthmatic attack,
4. Client is informed when and where to seek medication,
5. Client knows when to use the inhaler, and
6. Clients knows how to use the inhaler correctly.
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Clinic 2012
Tampin 93.3%
Gemencheh 87.1%
Jelai 96.7%
Air Kuning 86.7%
Gemas 84.4%
District Median 89.6%
SLIDE 14 Work Process
SLIDE 15 Community Nurse / Staff Nurse / Medical Officer NCD Service
• Initial clerking
• Explaining about all elements about asthma based on patient’s booklet
• Assess and examine patient based on asthma initial clerking and checklist
up to inhaler technique*
• Register in asthma registration book
• Giving appointment to patient
* And checking patient has filled up ACT correctly and jot down ACT score
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Further random audit on asthma cards at 3 clinics in February 2009 showed that
assessment and follow up care of asthmatic patients were not optimum. Patients
either came for exacerbations or just to take inhalers)
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Specific Objectives
1. To identify contributing factors to the low percentage of patients receiving
optimal assessment during follow up
2. To formulate intervention strategies to increase percentage of patients
receiving optimal assessment during follow up
3. To carry out remedial actions towards the objectives efficiently
4. To re-evaluate the effectiveness of remedial actions taken
SLIDE 4 Definition
Optimal assessment
Assessment of patients covering all of the following 6 criterias
1. Daytime symptoms
2. Nocturnal Symptoms
3. Limitation of activity
4. Need for reliever/ rescue
5. Use of nebuliser/ A&E visit
6. PEFR (percentage over predicted or personal best)
SLIDE 5
Indicator & Standard
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SLIDE 7 Problem identified Remedial Action
Immediate Long Term
2. Unestablished Development of Audit on the implementation in
local protocol implementation the clinics and identify problems
on Management protocol on related to it.
of Asthmatic Management of
Asthmatic patients in Periodic review of the local protocol.
patients in the
the clinic
clinic
SLIDE 8 Problem identified Remedial Action
Immediate Long Term
3. Inadequate Phase 1: Provision Regular checking of tools based on
assessment of assessment tools checklist twice a month.
tools in to all consultation,
clinics (Peak screening and
flow meter, treatment rooms.
mouth piece Phase 2:
& Peak flow Development on
normogram) “ASTHMA KIT”
SLIDE 9
Problem identified Remedial Action
Immediate Long Term
1. Inadequate Workshops on Regular assignments for AMO on
educational “Assessment & case studies
activities for Management of
Asthmatic Patients” Mentor – Mentee activities in
Health Care respective clinics
Providers for all health care
providers.
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Patient come
Patient come to to
healt clinic
healt clinic
Evaluate again
the asthma
SLIDE 11 DSA QA Indicator
SLIDE 12 QA Asthma: Any changes?
30 33 23 28 47 70.9
SLIDE 13 Together with the DSA…………Phase II
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MAIN OBJECTIVES:
1. To determine the level of asthma controll in Pendang District
2. To detect the main factor which caused the level of controlled asthma is low.
3. To plan a framework and implement the plan of action in controling the
bronchial asthma level.
4. Research and restudy regarding the plan of action is created for effective
detection and evaluation should be rule out.
Formula:
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Registration
N= 1246
Severity
Ref: Martinoz FD N
Filling system
SLIDE 4 Model Of Good Care
Process of care Criteria Standard
2. History taking History taking based on the criteria in the clinical practice 100%
guideline
4. Defaulter tracing All defaulter cases should be contact within 2 weeks from 100%
the actual appointment date.
5. Health education 1. All health care officer should attend the management 100%
of bronchial asthma course once a year.
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SLIDE 6 Technique of data collection
1. Questionnaire for health officer and patient (client)
2. Visit card for asthma patient is audited retrospectively to get the data
3. Analysis will be done by Pharmacist using the questionairre and interveiwing
the client.
4. Monitoring the inhaler techniquePemerhatian teknik menggunakan MDI.
5. Data will be analyze by the SPSS Vertion 16.
SLIDE 7 Inclusion criteria
- All adult bronchial asthma which registered actively since 6 months ago at
each 3 clinics in Pendang District
Exclusion criteria
- Bronchial asthma among pregnant mother
SLIDE 6 Controlled asthma based on CPG of Management of Bronchial
Asthma 2002
1. No difficulty in breathing, cough or tiredness
2. Able to do normal physical activity
3. Sleep well
4. No need to use reliever MDI
5. % Expected PEFR > 80% are expected
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Analysis of the data found that there were several contributing factors that led to cases
of uncontrolled bronchial asthma.
SLIDE 8 Data analyzed the factors which lead to uncontrolled bronchial
asthma
1. Weak monitoring system
Wrong inhaler technique All patient able to perform a 41% client performed a right
correct technique technique
2. Uneffective management
Monitoring of PEFR Should done to all asthmatic 48% of client who have PEFR
technique is not done at patient who come to the clinic reading. Screening counter did
the counter PEFR examination should be not do the PEFR monitoring at
done at the screening counter the 3 clinics in Pendang District.
Lack of knowledge All health care officer should have 31% - Satisfactory (skor >80%)
among the health officer the knowledge about asthma. 69% - Not satisfied
in asthma management.
Failure to iniate the All asthma patient must started 82 % using inhaler
treatment with inhaler with inhaler (MDI)
CPG as the guideline is All clinic is given the Asthma CPG 42% used the guidelines
not use in managing the and target of using it is 100%
patient
3. Patient compliancy
Factor Standard Result
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Wrong technique of 1. First consultation for all January 2010 until present
using the inhaler (MDI) 2. Demostrate the technique to all
the new patient
3. Corrected by pharmacist
4. Demonstrate by the patient
5. Evaluation by the health officer
6. 3 months and follow by year
2. Uneffective management
69 % of the health care 1. 100% of the health care officer Since December 2009
officer does not have who handling the asthmatic until present
enough knowledge patient should have adequate
about asthma knowledge. (Score >80%)
2. CME is conduct by the FMS or
medical officer. All staff should
attend this CME at least once a
year.
Only 82 % of patient 1. All patient need to be start with January 2010 until
using inhaler inhaler for asthma case by the present
Medical Officer or FMS.
2. Management record book
should be establish at 3 clinics in
the Pendang District
3. Random audit by FMS should
be rule out every 3 months
(systematically)
Asthma CPG is not used 1. Bronchial asthma CPG should be January 2010 until
and treatment is not develope present
based on the CPG
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1. Did not use the • Inhaler technoque monitoring January 2010 until present
MDI should be monitor by the Medical
Assistant and pharmacist via the
exchange card of MDI and MDI
inspection
2. Knowledge about • Reminder about the appointment January 2010 until now
asthma date by the Asthma Educator.
SLIDE 12 % of controlled bronchial asthma cases at Pendang district before
/ after improvement
SLIDE 13 Survey Results DSA
Criteria Before After innovation After innovation
innovation 2010 2011
a. Weak monitoring
1. MDI technique 41% 71% 79%
2. Defaulter tracing 0% 64% 89%
b. Uneffective handling
montoring
1. PEFR recruitment 48% 87% 95%
2. Staff knowledge 31% 82% 86%
3. Treatment based on CPG 48% 87% 95%
a. Non - compliance
1. Patient knowledge 56% 71% 79%
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SLIDE 15 Bronchial asthma cases in Pendang District
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SLIDE 17 Management of Bronchial asma patient at Pendang District by
Pharmacist
SLIDE 18 ABNA
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SLIDE 20 Research direction
This research is the first step of DSA team to improve and strengthening the
management of asthma all over Malaysia and also pediatric group.
References:
1. Appropriate Management Of Asthma: QAP Primary Health Care by KKM
2002: 10, 23, 24 & 25.
2. Asthma Registry Pendang.
3. CPG For Management Of Asthma KKM 2002.
4. Dr. Shahrul Bariyah Bt Ahmad. National Health And Morbidity Survey 2006
(NHMS III) Negeri Kedah Darul Aman 2008; 4,15.
5. Dr.Kuppuswamy RIyawoo. The Goal Is Total Asthma Control 2004
www.redorbit.com/news/health; 1-3.
6. Dr.Norzila Mohamed Zainudin. Asthma Control Beyond Symptoms. Issue 4,
Nov 2003.
7. Emmanouil Rovithis et al. Assessing the knowledge of bronchial asthma
among primary health care phyisician in Crete : A Pre and post test
following education course. 21 st May 2001.
8. R.Khatojia. Classifying Asthma Severity And Treatment Determinants:
National Guidelines Revisited. www.ejournal.afpm.org.my/2008v3n3/
asthma-severity, 1-3.
9. Prof Dr.Zainuddin Zin: Medical Tribune Towards Improved Asthma
Management In Asia: A Control Driven Approach. www.medical.tribune.
com by Glaxo Smith Kline.
10. www.guideline.gov/summary, 1-4.
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SLIDE 1 Introduction
SLIDE 2 Rational
Global Iniatiative For Asthma (GINA), Global Strategy For Asthma Management
and prevention 2009 (update)
• Management of asthma patient is based on level of control and not the
severity classification.
• Main aim of treatment is to achieve the target and maintain the clinical
control which included:
a. Asthma control evaluation
b. Treatment to achieve the control
c. Monitoring to maintain the control level
Specific objective
• To conduct a research and study the magnitude of problem in managing
and monitoring the level of asthma control among patient.
• Identify the cause of problem in monitoring without using GINA
• Identify step of improvement
• Evaluate the steps of improvement
SLIDE 4
Indicator
Target >50%
Achievement 17%
SLIDE 5 Model Of Good Care (MOGC)
Asthma Management
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SLIDE 7 Asthma controlled year 2009 till 2012
2012
2012
No Health Clinic 2009 2010 2011 (kriteria
(GINA)
lama)
1 KK Arau 17.2% 40% 43% 36.7% 77%
2 KK Beseri 23.3% 3.3% 6.7% 3.3% 16.6%
3 KK Kaki Bukit 40% 0% 12% 13.3% 86.7%
4 Kk Kampung Gial 23.3% 23.3% 26.7% 60% 57%
5 KK Kangar 15.7% 25.7% 16.7% 3.3% 16.7%
6 KK Kuala Perlis 13.3% 13.3% 0 56.7% 76.7%
7 KK Kuala Sanglang 20% 16.7% 46.7% 54.8% 53.3%
8 KK Padang Besar 10% 13.3% 40% 6.7% 90%
9 KK Simpang Empat 80% 3.3% 76% 83.3% 36.7%
SLIDE 8 Improvement measure conducted
1. Help the stadd on how to measure the level of asthma contril every time
the patient visit the clinic
2. Ensure all patients monitoring for each visit
3. Makesure that medical officer give the effective treatment according to the
level of control
4. Increase the quality of the asthmatic patient management in the clinic
5. Elevate the control of asthma among patient
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