Training Module

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Training Module
2
Why are we here today?

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

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Objectives

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

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Objectives

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

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Illustrative Cases
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Case 1

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

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Case 1

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

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Case 1

• What is your provisional diagnosis?

Asthma with allergic rhinitis
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Case 1

• How was the diagnosis of asthma made clinically?

The patient has typical symptoms of asthma
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Asthma

• Symptoms
• The four basic respiratory symptoms generally
  associated with asthma are
• Breathlessness (dyspnea)
• Wheezing (or noisy breathing)
• Cough
• Chest tightness

11
Asthma

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

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Asthma

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

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Asthma

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

14
Asthma

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

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Case 1

• How will you investigate the patient further?

At this point of time, treatment may be initiated
without any further investigations since asthma
is a clinical diagnosis. However, if there is a
doubt about the diagnosis, or presence of an
alternative diagnosis or complication, the
patient should be referred for investigations
and confirmation of diagnosis.
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Investigations

• SPUTUM FOR ACID-FAST BACILLI to exclude
  tuberculosis if the patient has persistent cough
  and expectoration for gt 3 weeks
• SPIROMETRY
• It is not mandatory but should be performed if
  the clinical data is confusing
• It provides an objective measurement of the
  presence and severity of airflow
  obstruction/limitation
• Demonstration of bronchodilator reversibility is
  helpful in making a more confident diagnosis of
  asthma and excluding COPD

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Investigations

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

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Case 2

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

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Case 2

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

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Case 2

• What is your provisional diagnosis?

COPD
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Case 2

• How was the diagnosis suspected clinically?

The patient has symptoms and signs suggestive of
COPD
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COPD

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

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COPD

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

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COPD

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

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Case 2

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

At this point of time, Ram Lal should undergo
sputum testing for AFB (at the nearest DOTS
centre to rule out tuberculosis) and if
negative, should be initiated on treatment for
COPD
26
COPD

• Diagnosis
• Investigations are generally required in patients
  with suspected COPD for
• Confirmation of diagnosis of COPD
• Exclusion of alternate diagnosis
• Assessment of severity
• Diagnosis of complications

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Investigations

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

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Investigations

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

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Case 3

• Rani, a 26 year old lady presents with
• History of breathlessness, wheezing and cough
  with minimal mucoid expectoration since the age
  of 12 years
• Initially these symptoms were episodic, usually
  occurring with change of season but with time,
  symptoms have became more severe and episodicity
  has been lost and now she has persistent symptoms
  throughout the year
• Her husband is a chronic smoker who smokes around
  10 bidis per day
• She cooks food by burning dried wood and dung

31
Case 3

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

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Case 3

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

Rani has asthma - based on her symptoms and
reversible airflow obstruction on spirometry,
her asthma is of moderate severity
33
Asthma Severity Classification
34
Case 3

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

35
Asthma

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

36
Asthma

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

37
Asthma

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

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Case 3

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

She should be initiated on controller medication
such as inhaled corticosteroids (ICS) with an
inhaled long-acting ß2-agonist (LABA) either by
metered dose inhaler (MDI preferably with
spacer) or dry powder inhaler (DPI). It should
be emphasized that these medications should be
taken regularly even if she is not having any
symptoms. Reliever medication such as inhaled
short-acting ß2-agonists (SABA) should also be
prescribed with the instructions that it is to be
taken strictly on an as-required basis and not
as a substitute for the controller drug(s)
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Asthma

• Management (Pharmacological)
• A stepwise approach to pharmacological therapy is
  recommended
• The aim is to achieve asthma control with the
  least possible medication
• The choice of treatment should be guided by
• severity of the patients asthma
• availability of various drugs and devices for
  asthma treatment in and around the patients
  place of living
• economic considerations

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Asthma

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

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Asthma

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

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Asthma

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

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Asthma

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

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Asthma

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

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Asthma

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

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Asthma

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

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Asthma

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

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Asthma

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

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Asthma

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

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Asthma

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

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Asthma

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

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Asthma

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

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Asthma Management based on severity
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Asthma Management based on severity

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

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Asthma Management based on severity

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

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Asthma Management based on severity
Day-time symptoms lt 1/week and night-time
symptoms ? 2/month - manage with reliever
medications alone Use of reliever medications gt
1/week use controllers Reliever medications -
taken as needed to prevent symptoms but not more
than 3/day - requirement gt 2/week indicates poor
control Once the goals for asthma achieved for at
least three months - gradually reduce maintenance
therapy - 25 reduction every three months Once
the patient is off all asthma medications
follow-up every six months
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Case 3

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

Her husband should be advised to quit smoking
since her asthma is likely to have been
aggravated by environmental tobacco smoke (ETS)
exposure. She should avoid exposure to smoke
while cooking (smokeless chullahs , improved
Ventilation). F/U - Rani should come for F/U
regularly till her symptoms are controlled -
after this, the frequency of F/U visits should
be reduced to one visit every 3 months. She
should report immediately in case of any
worsening of symptoms or increasing requirement
of reliever medications
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Asthma

• Management (Non-pharmacological)
• Patient education
• Education of patients assists in the management
  of their disease, helps them get the ability to
  attempt controlling their disease by themselves
  and establishes good rapport between the
  physician and patients
• Should be a continuous process and should include
  both the patient and his family members. It
  should help establish a partnership among
  physician, the patient and the family members.
• Should provide information about the disease and
  help them learn self-management skills

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Asthma

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

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Asthma

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

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Asthma

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

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Asthma

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

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64
Case 4

• Shanti Devi, a 58 year old lady presents with
• History of cough with expectoration and wheezing
  for the last 6 years. The symptoms used to worsen
  in the winters with episodes associated with
  fever and increased quantity of mucopurulent
  sputum that used to get relieved with short
  courses of oral medications prescribed by local
  practitioners. However, she was not taking any
  medications on a regular basis
• She denies history of smoking but her husband who
  passed away recently had been a chronic smoker
  who used to smoke 2 packs of cigarettes everyday

65
Case 4

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

66
Case 4

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

Shanti Devi has COPD - based on her symptoms and
signs, she has moderate COPD
67
COPD Severity staging without spirometry
68
COPD Severity staging with spirometry
69
Case 4

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

70
COPD

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

71
COPD

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

72
Case 4

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

She should be initiated on inhaled
bronchodilators - a combination of inhaled long
acting anticholinergic (tiotropium) with an
inhaled LABA (e.g. formoterol) may be an
appropriate initial choice. Reliever medication
(inhaled SABA) should also be prescribed on an
as-needed basis. If her symptoms are not
controlled, sustained release oral theophylline
preparations may be added to inhaled drugs. She
also may benefit from the addition of ICS in high
doses
73
COPD Management according to severity
Tobacco cessation and pulmonary rehabilitation
are important at all stages
74
COPD Management based on severity

• At risk (stage 0) cessation to smoking (or
  other forms of tobacco) exposure is the only
  intervention required for patients in this stage
• Mild COPD (stage 1) rapid-acting inhaled
  bronchodilator (like SABA or ipratropium) may be
  taken as needed to relieve symptoms
  (sustained-release theophylline is an alternative
  if patient is not taking inhaled drugs)

75
COPD Management based on severity

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

76
COPD

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

77
COPD

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

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COPD

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

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COPD

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

80
Case 4

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

She should be educated about her disease and the
need for avoidance of risk factors and should be
kept on regular follow up
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COPD

• Management (Non-pharmacological)
• Patient education (same as for asthma)
• Avoidance of exposure to risk factors
• Pulmonary Rehabilitation (referral to a higher
  centre)
• Regular follow up (same as for asthma)

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COPD

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

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COPD Management
Brief strategies to help the patient willing to
quit smoking
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COPD

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

85
COPD

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

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

• Intensive care for acute exacerbation
• Rehabilitation for stabilized patient
  domiciliary oxygen, appropriate nutrition and
  respiratory physiotherapy

Good response
Poor response
Treatment
Continue treatment
Complications
Good response
Poor response
Follow up
Good response
Tertiary Care Level
Secondary Care Level
Primary Care Level
87
Case 5

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

88
Case 5

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

89
Case 5

• What is your provisional diagnosis?

Pritam has left ventricular failure
90
Case 5

• How was the diagnosis suspected clinically?

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

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

He should undergo ECG and echocardiography and
be initiated on treatment for heart failure.
Referral to a secondary care level for further
evaluation and management should be appropriate
92
Case 6

• Pushkar, a 46 year old male presents with
• History of cough with expectoration,
  breathlessness and fever for the past 3 months
• He has also noticed streaky hemoptysis as well as
  weight loss of approximately 6 kg and a reduction
  in appetite
• He denies history of wheezing or chest pain
• He is a chronic smoker who smoke around 15 bidis
  per day

93
Case 6

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

94
Case 6

• What is your provisional diagnosis?

Pulmonary Tuberculosis
95
Case 6

• How was the diagnosis suspected clinically?

Even though the patient is a smoker and has
symptoms of cough with expectoration and
breathlessness, the diagnosis is not COPD
because in addition, he has hemoptysis, fever
and constitutional symptoms, all of which are
suggestive of active pulmonary tuberculosis
96
Case 6

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

He should undergo sputum analysis for acid fast
bacilli and chest x-ray
97
Differential Diagnosis

• Symptoms
• One should get alerted to the possibility of
  presence of an alternative or a coexisting
  disease if the following exist
• fever
• weight loss
• hemoptysis
• excessive and purulent sputum
• chest pain
• orthopnea and paroxysmal nocturnal dyspnea
• Such diseases could include bronchiectasis,
  tuberculosis, ischemic heart disease, left
  ventricular failure and lung cancer

98
Differential Diagnosis

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

99
Summary
100
Asthma

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

101
Asthma

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

102
COPD

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

103
COPD

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

104
Appendix AOverview of asthma and COPD
105
Introduction Overview

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

106
Airflow limitation resulting from a variable
mixture of loss of alveolar attachments,
inflammatory obstruction of the airway and
luminal obstruction with mucus
Peter J Barnes. Chronic Obstructive Pulmonary
Disease. N Engl J Med 2000 343 269-280.
(Reproduced with permission)
107
NORMAL AIRWAY
AIRWAY IN PATIENTS WITH AIRFLOW OBSTRUCTION
Airway lumen
Airway wall
Smooth muscle
Mucus glands
Smooth muscle hypertrophy
Inflammation and edema
Airway narrowing
Mucus plugging
Mucus gland hypertrophy and hyperplasia
108
Introduction Overview

• COPD
• Includes chronic bronchitis and emphysema
• It is generally difficult to separate out the two
  conditions, hence they are grouped together as
  COPD
• Currently it is the 5th leading cause of death in
  the world (4.8 of all deaths in 2002)
• Further increases in prevalence and mortality are
  predicted (7.9 of all deaths by 2030)

109
Introduction Overview

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

110
Introduction Overview

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

111
Introduction Overview

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

112
Introduction Overview

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

113
Introduction Overview

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

114
Introduction Overview

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

115
Introduction Overview

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

116
Introduction Overview

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

117
Introduction Overview

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

118
Introduction Overview

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

Foods are not commonly established triggers of
asthma
119
Introduction Overview

• Natural history of Asthma
• Natural history of asthma is variable
• Onset can occur at any age but commonly tends to
  affect children and young adults
• Generally severity of asthma in adult life
  parallels its severity during childhood
• 5-10 of children with mild asthma go on to
  develop severe asthma later in life

120
Introduction Overview

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

121
Appendix BDifferences and similarities between
asthma and COPD
122
Asthma COPD Similarities

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

123
Asthma COPD Differences
124
Asthma COPD Differences
125
Asthma COPD Differences
126
Asthma COPD Differences
127
Asthma COPD Differences

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

128
Appendix CDrugs their dosages
129
Equivalent doses of ICS
Medication inserts for HFA preparations should be
carefully reviewed for the correct dosage level
130
SABA

• Includes the following drugs
• Salbutamol
• Terbutaline
• Levosalbutamol
• Effect
• Inhaled form
• Onset 1-5 minutes
• Duration 3-6 hours
• Oral form
• Duration 6-8 hours

131
Doses of SABA (salbutamol)
132
Doses of SABA (terbutaline)
133
Long-acting drugs

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

134
Other Drugs
135
Appendix DMeasurements and devices useful in
management of asthma and COPD
136
SPIROMETRY

• Definitions
• Obstructive defect FEV1/FVC ratio lt 70
• Bronchodilator reversibility increase by 12
  AND 200 mL over the baseline values (either FVC
  or FEV1) after 200 µg of inhaled salbutamol
• Presence of a post-bronchodilator FEV1lt80 of the
  predicted value in combination with a FEV1/FVC
  lt70 confirms the presence of airflow limitation
  that is not fully reversible

137
PEAK EXPIRATORY FLOW (PEF)

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

138
The PEF Meter

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

139
The PEF Meter

• One hard, fast blow

140
PEF Monitoring

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

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