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LIFE TIME HAPPINESS
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When you can't breathe,
nothing else matters
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Dr.Sarma@works

CD format of todays presentation is ready
1. Asthma, COPD and Basics of Spirometry
In addition it, also contains
2. ECG workshop presented earlier
3. Guidelines on Hypertension treatment
This can be used in Computer & DVD player
Important Announcement
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1. ACCP www.chestnet.org
2. ATS www.thoracic.org
3. BTS www.brit-thoracic.org.uk
4. COPD profess. www.copdprofessional.com
5. GOLD www.goldcopd.com
6. NICE www.nice.uk.org
7. Chest Net www.chestnet.net
8. CDC www.cdc.nih.gov
9. NAEPP www.naepp.nhlbi.org
10.COPD Rapid series by ELSEVIER
COPD and Asthma Resources
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CHRONIC LUNG DISEASES
Pulmonary Tuberculosis
Restrictive lung diseases
Suppurative lung disease
Obstructive lung diseases
Bronchial Asthma
Chronic bronchitis
Emphysema and
Their differentiations
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AN OVERVIEW - GINA
MANAGEMENT GUIDE LINES
Dr. Sarma.R.V.S.N., M.D., M.Sc
(Canada)
Consultant Physician and chest specialist
# 5, Jayanagar, Tiruvallur 602 001
+ 91 9894- 60593, (4116) 260593
ASTHMA
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WHAT IS ASTHMA ?
Primarily it is an allergic inflam-
matory disorder of the airways
Infiltration of mast cells, eosinophils
and lymphocytes
Secondary broncho-constriction
Airway hyper-responsiveness
Recurrent episodes of wheezing,
coughing and shortness of breath
Airflow limitation is variable and
often reversible and wide spread
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BURDEN OF ILLNESS
15- 20 million asthmatics in India.
A recent study conducted in Delhi
established asthma prevalence to be
12% in school children.
Significant cause of school/work absence.
Health care expenditures very high.
Morbidity and mortality are on the rise.
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THE HUGE GAP
Patients are not detected
Do not seek medical attention
No access to health service
Stigma associated with the label
Broken marriages, alliances
Missed diagnosis (bronchitis, LRTI)
MECHANISM OF ASTHMA
INFLAMMATION
Risk Factors (for development of asthma)
Airway
Hyper responsiveness
Airflow
Limitation
Symptoms- (shortness of
breath, cough, wheeze)
Risk Factors
(for exacerbations)
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ASTHMA : PATHOLOGY
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RISK FACTORS FOR ASTHMA
Predisposing Factors
Atopy ( IgE)

Causal Factors
Indoor Allergens
Domestic mites
Animal Allergens
Cockroach Allergens
Fungi moulds
Outdoor Allergens
Pollens
Fungi, RSV
Occupational
Sensitizers
Contributing Factors
Respiratory infections
Small size at birth
Diet
Air pollution
Outdoor pollutants
Indoor pollutants
Smoking
Passive Smoking
Active Smoking
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HOUSE DUST MITE
Use bedding encasements
Wash bed linens weekly
Avoid down fillings
Limit stuffed toys to those
that can be washed
Reduce humidity level
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COCKROACHES
Remove as many
water and food
sources as
possible to avoid
cockroaches.
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PETS
People allergic to pets should not
have them in the house.
At a minimum, do not allow pets in
the bedroom.
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MOLDS - FUNGUS
Eliminating mold may help control asthma exacerbations.
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History and patterns of symptoms
Physical examination
Measurements of lung function
Peak flow meter
Spirometry
DIAGNOSIS OF ASTHMA
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PATIENT HISTORY
Has the patient had an attack or recurrent
episodes of wheezing?
Does the patient have a troublesome cough,
worse particularly at night, or on awakening?
Does the patient cough after physical activity
(eg. Playing)?
Does the patient have breathing problems
during a particular season (or change of
season)?
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MAIN SYMPTOM CLUES
Do the patients colds go to the chest or
take more than 10 days to resolve?
Does the patient use any medication ?
(e.g. bronchodilator) when symptoms
occur ? - Is there a (relief) response?
If the patient answers YES to any of the
above questions, suspect asthma.
Remember, the commonest cause of
persistent cough is asthma
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PHYSICAL EXAM
Wheeze -
Usually heard without a stethoscope
Dyspnoea -
Rhonchi heard with a stethoscope
Use of accessory muscles
Remember -
Absence of symptoms at the time of
examination does not exclude the
diagnosis of asthma
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Hyper-expansion of the thorax
Increased nasal secretions or
nasal polyps
Atopic dermatitis, eczema, or
other allergic skin conditions
PHYSICAL EXAM
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SCREENING TEST
Diagnosis of asthma can be suspected by
demonstrating the presence of airway
obstruction using Peak flow meter.


Peak Flow Meter is a basic
tool in a GPs office
PEFR amplitude ?
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DIAGNOSTIC TEST
Diagnosis of asthma can be
confirmed by demonstrating
the presence of reversible
airway obstruction using
Spirometry.
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SPIROMETRY
Let me now take you through to
the understanding of the basics
of spirometry
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SPIROMETRY
Basic Issues
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LUNG FUNCTION TESTS
Tests of Ventilation
Tests of Diffusion
Tests of Perfusion
Tests for V-P
Mismatch

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LUNG FUNCTION TESTS
Tests of Ventilation
Tests of Diffusion
Tests of Perfusion
Tests for V-P
Mismatch
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VENTILATION
Peak Expiratory Flow Rate
Simple, Peak flow meter is used
Flow volume loop , Flow time
curve
Detailed, Spirometry is used
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PEAK FLOW METER
Diagnosis of ASTHMA or COPD can be
confirmed by demonstrating the presence
of airway obstruction using Spirometry.
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PEFR - Pros and Cons
Advantages
With in 1 to 2 minutes,
Inexpensive (meter costs less than Rs.1000)
Simple, useful for frequent follow up use
Disadvantages
Very much effort dependent
Insensitive to small changes
Small airways cannot be assessed
Large inter & intra subject variation;accurate
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SPIROMETRY
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Spirometry - Pros and Cons
Advantages
Evaluates smaller as well as larger airways
Relatively easy to use and maintain
Reversibility can be tested with IBD and steroids
Diagnostic as well as management assessments
Disadvantages
Cost about 50,000 + computer and printer
Takes time to perform 10 to 15 minutes
Requires training at least one day course
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Spirometry Maneuver
In single breath test
A few normal tidal respirations
Then deeeeep inspiration
Momentary breath holding
Very forced and fast expiration
As hard and as fast as he/she can blow out
Then deep, quick and full inspiration
Repeat at least 3 times take the best
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Spirometry Results
FVC Forced Vital Capacity
FEV1 Forced Expiratory Volume
in the first second
FEV1FVC Ratio of the above two
PEFR Peak Expiratory Flow Rate
FET Forced Expiratory Time
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Spirometry Normal Values
1. There are no fixed Normal values
2. Dependent on age, sex, ht, wt, ethnicity
3. Observed value expressed as predicted value %

FVC Normal if > 80% of predicted
FEV1 Normal if > 80% of predicted
FEV1/FVC At least 75%
PEFR Normal if > 80% of predicted
FET Less than 4 seconds
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Obstructive v/s Restrictive
Parameter Normal Obstructive Restrictive
Problem Air out and
Air in normal
Unable to get
Air out
Unable to get
Air in
FVC 80 % of pred Normal or ,TLC
FEV1 80 % of pred -80% or less Normal
FEV1 FVC Min. of 75% -70% or less Normal or
PEFR 80 % of pred -80% or less Normal
FET in sec Less than 4 Prolonged > 4 Normal - < 4
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Flow-Volume, Volume-Time Graphs
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Normal Flow-Volume Loop
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Flow-Volume Loop in disease
Mild reversible obstruc Severe irreversible obstr Severe restrictive dis
ASTHMA COPD ILD
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Office Spirometry
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BACK TO ASTMA
Now, with this understanding of
spirometry, let us proceed to look
at the management of Asthma
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CLASSIFICATION OF SEVERITY
STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent
STEP 1
Intermittent
The presence of one of the features of severity is sufficient to place
a patient in that category.
Global Initiative for Asthma (GINA) WHO/NHLBI, 2002

Symptoms
Nighttime
Symptoms
FEV1
CLASSIFY SEVERITY
Clinical Features Before Treatment
Continuous
Limited physical
activity
Daily
Use b2-agonist
daily
Attacks affect
activity
>1 time a week
but <1 time a day
< 1 time a week
Asymptomatic
and normal PEF
between attacks
Frequent
>1 time week
>2 times a month
<2 times a month
<60% predicted
Variability >30%
>60%-<80%
predicted
Variability >30%
>80% predicted
Variability 20-
30%
>80% predicted
Variability <20%
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GOALS IN ASTHMA CONTROL
Achieve and maintain control of symptoms
Prevent asthma episodes or attacks
Minimal use of reliever medication
No emergency visits to doctors or hospitals
Maintain normal activity levels, including
exercise
Maintain pulmonary function as close to normal
as possible
Minimal (or no) side effects from medicine
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TOOL KIT WE HAVE
Relievers (Quick)
Preventers (long term)
Peak Flow meter
Spirometry
Patient education
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ASTHMA Rx. in INDIA TOADAY
Completely control symptoms and
Make their life normal
As good as abroad (even better)
General practice physicians
Doesnt need Chest Physicians !
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IT IS A DUAL PROBLEM
1. Bronchial inflammation perpetual
1. Allergic inflammation and edema
2. Inflammatory mediators perpetuate
3. edema and excite bronchospasm
4. Bronchial hyper reactivity to triggers
2. Bronchospasm acute attacks

This needs two different types of
medicines relievers & preventers
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WHAT ARE RELIEVERS ?
Spasm needs reliever
Bronchodilator drugs
Rescue medications
Quick relief of symptoms
Used during acute attacks
Action lasts for 4-6 hrs
Not for regular use at all
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RELIEVERS
Short acting b
2
agonists - SABA
Salbutamol, Terbutaline
Levo-salbutamol (Levolin)
Anti-cholinergics
Ipatropium
Xanthines
Theophylline (Deriphyllin group)
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Prevent future attacks
Reduce allergic inflammation
Reduce inflammatory mediators
Reduce hyper-responsiveness
Long term control of asthma
Prevent airway remodeling
For regular use well or ill
WHAT ARE PREVENTERS ?
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PREVENTERS
Xanthines
Theophylline SR
Mast cell stabilizers
Sodium cromoglycate
Nedocromil sodium
Ketotifen, Ceterizine
Combinations
Salmeterol/Fluticasone
Formoterol/Budesonide
Salbutamol/Beclomethasone
Corticosteroids
Prednisolone, Betamethasone
Beclomethasone, Budesonide
Fluticasone
Long acting b2 agonists-LABA
Bambuterol, Salmeterol
Formoterol, Bambuderol
Anti-leukotrienes
Montelukast, Zafirlukast, Pranlukast
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CERTAIN ABBREVIATIONS
ICS Inhaled corticosteroids
IBD Inhaled bronchodilators
SABA Short acting agonists
LABA Long acting agonists
LTA Leukotrine antagonists
OCS Oral corticosteroids
SR Sustained release
AchB Acetyl choline blockers
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NEW APPROACHES
Omalizumab injection
Monoclonal antibody against
Immunoglobin E (anti-IgE)
Monoclonal antibody to block
the allergic antibody, IgE

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PLEASE REMEMBER
If our patient uses reliever medication
every day, or even more than three or
four times a week, preventer medication
must be added to the treatment plan and
reliever medication has to be with drawn.

GINA Workshop Report,
December 2000
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Are we giving the right drug ?

Are we giving the drug in right form ?

Are we using the correct technique ?
LET US QUESTION
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WHAT HAPPENS WITH WRONG Rx. ?
Normal
Inflamed
(Asthma)
Partly Treated
Fixed Obstruction
(Lead Pipe)
Remodelled
Airway
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THE STORY OF ASTHMA TREATMENT
Normal
Regular
Inhaled
Steroid
Partly
Treated
Inflamed (untreated)
Remodeled
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All Asthma drugs should ideally be
taken through the inhaled route.
MOST IMPORTANT
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WHAT CHANGES THEIR LIFE ?
ICS 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
ICS
Inhaled corticosteroids
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Corticosteroids ??
Inhaled medicines ??
LET US BELIEVE FIRST
Patients wrong belief
Parents / Grand parents
Neighbours / friends
First of all, let us believe in science
Let us explain and convince them
Let us change their lives to happy lives
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Instead of asthma controlling
our patient

REMEMBER
allow our patient to
control his / her asthma
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WHY INHALATION Rx.
Oral
Slow onset of action
Large dosage used
Greater side effects
Erratic absorption
Not useful in acute
illness
Inhaled route
Rapid onset of action
Less amount of drug
Drug delivered to
the site of mischief
Better tolerated
Treatment of choice
in acute symptoms
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PREVENTERS
Inhaled corticosteroids
Budesonide/ beclomethasone/
fluticasone use any
Start (400-1000 mcg/day approx. in
2 divided doses)
Maintain for 3 months
Taper slowly and keep at 200 mcg
Safe for long-term use (years)
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They are very safe
Even in small children for several years
30% of Olympic athletes use ICS
Not anabolic (performance-enhancing)
steroid
Even highest ICS dose is safer than low
dose oral steroid or beta agonist
Best Addiction for asthmatics
ICS HOW SAFE ?
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ICS SAFE EVEN FOR A CHILD?
400 mcg/day (budesonide)
Over 9 years of continuous use
No growth retardation
Uncontrolled asthma causes growth
retardation

Pedersen & Agertoft NEJM 2000
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PREGNANCY AND ASTHMA
Dont 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 Supplement
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ICS not Effective ?
Check Inhaler
Technique /
Check Regular
Use
Add LABA
Formoterol /
Salmeterol
Increase dose
of inhaled
steroid
Add Leukotriene
modifier
Add SR
Theophylline
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Step up and down - ACUTE
SABA (IBD) in full doses
SABA Increase frequency or Nebulize
SABA as above + IPA (IBD), then add
OCS (Prednisolone) 30-60 mg for 3 to 10 days - add
ICS (1000 mcg) / day and maintain for 6 weeks minimum
Gradually bring down doses and maintain with ICS
If symptoms are not relieved
Check the technique and the compliance with Rx.
Look for aggravating factors like
GE Reflux, Emotions/ stress, Sinusitis
Allergic Rhinitis, Persistent allergens
No role for Theophylline; Oral SABA or LABA not very useful
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The Step Care Approach - Prevent
ICS
ICS + LABA (IBD)
ICS + LABA (IBD) + Double Dose ICS
ICS (DD) + LABA + LTA (oral)
ICS (DD) + LABA + LTA + OCS
ICS (DD) + LABA + LTA + OCS + TIO (IBD)
SR Theophylline may be add on
SABA or LABA Oral + IPA (IBD) may be useful add on
No long acting steroid injections
No injectable or short acting Theophylline
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Leukotriene Modifiers
Oral leukotrine antagonist anti inflammatory
Not as effective as inhaled steroid
May be first-line for 2 to 5 yr. olds.
Montelukast available; Zafirlukast is not in India
4 mg, 5 mg, 8 mg tabs available
Can be add on to ICS, IBD inhalers

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NOT ALL ARE SAME !!
Beclomethasone 6 hrly + Salbutamol 6
th
hrly
Budesonide 12 hrly + Salmeterol 12 hrly
Salmeterol 12 hrly + Ipatropium 12 hrly
Fluticasone 24 hrly + Formoterol 24 hrly
Formoterol 24 hrly + Tiotropium 24 hrly
Choice is based on
1. If need is urgent and uncontrolled 6 hrly
2. If need is maintenance, well contr. 12 hrly
3. If stabilized and wants convenience 24 hrly
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Formoterol + Budesonide
combination - the Flexible Preventer
A
s
t
h
m
a

s
i
g
n
s

Time
2x2
2x2
1x1
1x2
1x2
Quickly
gains control
Maintains
control
Asthma
worsening
Maintains
control
Reduce to
lowest
adequate
dose that
maintains
control
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Why doctors dont use
inhalation therapy
Status quo :
my practice is good or great
Oral therapy is easy
Too busy
Difficulty in convincing
Cost
Headache to explain
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DRUG DELIVERY OPTIONS
Metered dose inhalers (MDI)
Dry powder inhalers (Rotahaler)
Spacers / Holding chambers
Nebulizers
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Demonstration of
the correct technique
Ask the patient to demonstrate to
you the technique
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pMDI Metered Dose Inhalers
Rotahalers, Diskhalers
Spacehalers
Nebulizers
Oxygen mixed delivery
Oral tablets, syrups
Parenteral I.M or I.V use
1. Dexterity
2. Hand grip strength
3. Co-ordination
4. Severity of COPD
5. Educational level
6. Age of the patient
7. Ability to inhale and
synchronize
DRUG DELIVERY - OPTIONS
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WHAT DRUG DELIVERY METHOD ?
Very young or very old MDI + LV Spacer
Elderly MDI + SV spacer
Young children > 7 yrs DPI (Rotahaler)
Adults edu. understood MDI alone
Adults no co-ordination DPI (Rotahalers)
Clinic setting MDI + Spacer
Clinic - emergency Nebulizer
Choice is to be individualized
Trial and error may be needed
Cost may be a factor
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DRUG DELIVERY - OPTIONS
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Spacer
Spacehaler
Rotahaler
Dry powder Inhaler
Metered dose
inhaler or MDI
INHALATION DEVICES
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MDI + LARGE VOLUME SPACER
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ROTAHALER DRY POWDER
Overcomes hand-lung coordination
problems encountered with MDIs.
Can be easily used by children, elderly and
arthritic patients.
Can take multiple inhalations if the entire
drug has not been inhaled in one inhalation.
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THE ZEROSTAT ADVANTAGE
1. Non - static spacer made up of polyamide material
2. Increased respirable fraction Increased deposition of
drug in the airways
3. Increased aerosol half - life Plenty of time for the
patient to inhale after actuation of the drug
4. No valve No dead space Less wastage of the drug
5. Small, portable, easy to carry Child friendly
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DISKHALER NEBULISER
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NEBULISED THERAPY
1. Severe breathlessness despite using inhalers
2. Assessment should be done for improvement
3. Choice between a facemask or mouth piece
4. Equipment servicing and support are essential
5. Dosage 0.5 ml of Ipatropium +
0.5 ml of Salbutamol + 5 ml of NaCl (not DW)
6. If decided to use ICS (FEV1 < 50%)
0.5 ml of Budusonide is added to the above
6. 15 minutes and slow or moderate flow rate
7. Can be repeated 2 to 3 times a day Mouth Wash
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PATIENT EDUCATION
Explain nature of the disease (inflammation)
Explain action of prescribed drugs
Stress the need for regular, long-term therapy
That way only we can convince
Allay fears and concerns
Peak flow testing
Symptom, treatment diary
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PATIENT EDUCATION
Asthma is a common disorder
It can happen to anybody, May not be life long
It is not caused by supernatural forces
Asthma is not contagious, All kin neednt be affected
Recurrent attacks of cough with or without wheeze
Between attacks people with asthma lead normal
lives as anyone else
In most cases, there is some family history of allergy
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Asthma can be effectively controlled, although it
cannot be cured.
Effective asthma management programs include
education, objective measures of lung function,
environmental control, and pharmacologic therapy.
A stepwise approach to pharmacologic therapy is
recommended. The aim is to accomplish the goals
of therapy with the least possible medication.
PATIENT EDUCATION
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A little time spent talking
to our patients - really
is a great investment.

This may make all the difference
between a happy life and
pulmonary invalidity
YOURS FAITHFULLY REQUESTS
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Can We dare to make
them pulmonary invalids ?
LET US GIVE THEM
LIFE TIME HAPPINESS