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Asthma Training Module - 2013
Asthma Training Module - 2013
Asthma Training Module - 2013
Asthma By Consensus
IAP
National Guidelines for the Management of Childhood Asthma
2013 Update
Todays tasks
Must know
Basic pathophysiology Diagnosis of asthma Long term management Managing acute attac s !emonstration time
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PEP Talk
Asthma
$haracteri%ed by
Airway
IN!)C*+, Allergens Maternal smo ing' $hemicals' Air pollutants' (irus infections
Airway ,yper-responsiveness
Airflow Limitation
T+IGG*+,
")ercise $old Air' *+2 Particulates (irus infections
,0MPT/M ,
,tru#tural #hanges
Airway remodeling
Time
!iagnosis of asthma
The story begins00
Clini#al e(aluation
Ascertain diagnosis 1dentify #o%mor$id #onditions Thin of alternate diagnosis 2rade se(erity 1dentify triggers
!iagnosis of asthma
Case11Ar'it
& year old Arpit was seen for recurrent cough for about 3 year. ,is mother reported that he fre5uently had colds which went to the chest
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Ask for11
6ecurrent #ough3 6ecurrent whee4e3 6ecurrent $reathlessness3 A#ti(ity5stress indu#ed cough7whee%e8 No#turnal cough8 Tightness of chest8
Ar'it #ontinued
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.ook for11
,igns of airf low o$stru#tion /ther features of ato'y
Ato'i# dermatitis 5 2enerali%ed whee4e Prolonged e7'iration *#4ema Allergi# rhinitis 5
#on8un#ti(itis In the hy'erinf interval period, be normal $hest lation chest examination may
Ar'it #ontd
Arpit<s mother reported that every episode started with a cold and snee%ing. Arpit often reported an earache and had ta en multiple courses of antibiotics for ear infections. =1s Arpit a mouth breather and snorer 8> 1 as ed0
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Ascertain diagnosis
Co mor$id #onditions
Allergi# rhinosinusitis
PEP Talk
*nee%ing in the morning' nasal itching 6unning 7Bloc ed nose' snoring' mouth breathing
Adenoidal hy'ertro'hy
.ook for11
*igns of allergic rhino-sinusitis
?asal mucosa B edema' pale or violaceous $lear nasal discharge 7Bloc ed nose Post nasal drip $obblestone pharyn)
Consider
(irus associated whee%e Aspiration syndromes e.g. 2" reflu) disease $ongenital airway anomalies $ongenital heart disease Cloo for murmursD
Consider
6hino sinusitis Foreign Body Tuberculosis Pertussis
Consider
Ar'it1 #ontinued
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Typical history $B$ B may show eosino'hilia <ray chest-may be normal5hy'erinf lated Predi#ta$le $ron#hodilator res'onse
Investi ations help to rule out alternate dia noses, not to prove asthma!
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"hats in a name 3
=But doctor> she e)claimed' =AsthmaH And no breathlessness80 Are you sure8>
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PEP Talk
Arpit<s mother as s whether lung function testing 7 allergy testing will help to prove what 1 am telling her8
$an P"F6 help in the diagnosis 8 As ed the physician who accompanied the an)ious family8
PEP Talk
Peak f low
has a limited role in diagnosis Best used for monitoring
Coming to terms
=1 now understand what you have said so far0> said Arpit<s mom. =Tell me' doc' what e)actly is asthma8>
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Asthma #om'onents
;ealthy Airway
Alveolar partition
P"P Tal
Asthmati# Airway
1nflammation and swelling Mucus and plasma outpouring
,ow will you manage this case and counsel the family8
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A#ute Bron#hiolitis
First episode of whee%ing in a young child Cup to 2 yrsD *tarts with cory%a' usually with fever $lustered in winter and rainy months ?o atypical features
PEP Talk
a family h7o asthma7atopy or personal h7o atopy "ollow up #or other $uali#yin #eatures be#ore assi nin a dia nosis o# asthma
PEP Talk
sibling - dou$les ris one parent - dou$les ris $oth parents - tri'les ris
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#!
##
,ummary so far11
Diagnosis is #lini#al
6ecurrent episodes of airflow obstruction are present Airway obstruction is reversible Alternative diagnoses are e)cluded $o-morbid conditions are identified The under-; whee%er is a mi)ed bag
!rugs
+elie(ers
Esed in a need based manner for treatment of bronchospasm and to relieve acute attac s
Controllers
Esed on daily long term basis for control of inflammation and to prevent further attac s
Controllers
Inhaled
Corti#osteroids9IC,: .ong a#ting inhaled >%agonists 9.ABA:
/ral
.eukotriene antagonists Theo'hylline % ,+ /ral 'rednisolone
Inhaled Corti#osteroids
*stimated e2ui'otent daily doses of IC, Children @ A> years
Drug
Budesonide Fluticasone Beclomethasone
Medium dose ,igh dose CLgD CLgD M244-#44 M244-;44 M244-#44 M#44 M;44 M#44
Inhaled Corti#osteroids
*stimated e2ui'otent daily doses of IC, Children B A> years
Drug
Budesonide Fluticasone $iclesonide Beclomethasone
Medium dose ,igh dose CLgD CLgD M#44-/44 M2;4-;44 M3&4-!24 M;44-3444 M/44 M;44 M!24 M3444
"hy ,teroids 3
,u'erim'osed a#ute inf lammation A#ute inf lammation
,ystemi# steroids
,tru#tural #hanges
,tru#tural #hanges
Time
Time
Inhaled steroids
%'ra#ti#e 'oints
Anti%inf lammatory effe#t evident in 3-2 wee s.
PEP Talk
Local adverse effects B thrush7dysphonia minimi4ed $y s'a#er5gargling Esually re5uired inhaled doses- negligi$le systemi# effects Prolonged high dose - monitor growth and eyes CcataractsD.
PEP Talk
Uncontrolled asthma is more li%ely to cause rowth #ailure than usually needed doses o# inhaled steroids
.eukotriene antagonists
% 'ra#ti#e 'oints
Kea antiBinflammatory effect compared to 1$* Add-on in moderate 7severe asthma 1nferior to 1$* in mild persistent asthma Eseful in ")ercise induced asthma May be used when concomitant allergic rhinitis Montelu ast approved for M & months of age
,+%Theo'hylline
% 'ra#ti#e 'oints
Anti%inf lammatory5immunomodulator $urrently used as a #ontroller Esed as adJunct to inhaled steroids Colder childrenD
+ole of s'a#ers
PEP Talk
"liminate need for hand - breath #o%ordination +edu#e lo#al side effe#ts of inhaled steroids Im'ro(e drug deli(ery !ilute taste of inhaled sprays. "liminate #old freon effect Cwith $F$D
Ty'es of s'a#ers
*mall volume vs large volume (alved vs non valved Polyamide vs polycarbonate
USE A SPACER
+ole of mask
*pacer with well fitting mas
PEP Talk
Below O ! years or anyone who cannot breathe consciously through mouthpiece of spacer.
*pacer alone
Above O ! years' or +nce a child learns to breathe through mouthpiece mas should be removed.
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The D ste's
3. ")plain advantages of inhaled therapy
2. Dispel myths and fears !. *elect an appropriate device #. Demonstrate how to use the selected device
PEP Talk
/ral
1ndirect ,igher *low
Adverse effects Mild-none 2reater Smaller dose, target delivery, quic er action, lesser side e##ects
The D ste's
")plain advantages of inhaled therapy
PEP Talk
N/ *m'hasi4e mi#rograms
1s inhaler therapy Gaddictive<8 N/ None of the drugs #ause de'enden#e 1s inhaler therapy e)pensive8 N/ Initially yesC $ut ultimately N/ 1s inhaler therapy easy for children to use8 0*,
The D ste's
")plain advantages of inhaled therapy Dispel myths and fears
PEP Talk
PEP Talk
I O! years B MD1 P spacer P mas M O! years B MD1 P spacer M & years B MD1 P spacer - Dry Powder 1nhalerCDP1D is an option
PEP Talk
PEP Talk
,ome ,ospital
- MD1 P spacer P mas 7 DP1 - MD1 P spacer P mas - ?ebuliser in severe episodes
The D ste's
")plain advantages of inhaled therapy Dispel myths and fears *elect an appropriate device
Amit 9re#a':
E the first time whee4er
1ts December. Amit' Arpit<s younger brother is = months old. ,e presents with a whee%e for the first time along with a fever' cold and cough. =?ot againH> e)claimed the parentsH
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Bron#hiolitis
Management
A#ute e'isode
+)ygen in severe cases +ral 7 nebulised @2 agonists ?ebulised adrenaline is preferred *ymptomatic therapy
?ot indicated
Indu 9re#a':
% the early whee4er
1ndu' who is Arpit<s neighbour' has come to see you. *he is eighteen months old and she has been getting recurrent cough' cold' fe(er and whee%ing since she 8oined a #re#he si) months ago..
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+)ygen in severe cases +ral71nhaled @2 agonists *teroids B when severe or with associated ris factors
1f severe or fre5uent episodes CM once a monthD Daily 1$* may be beneficial 1ntermittent LT6A- Limited effect
,ushil 9re#a':
E the multi trigger whee4er
*ushil' > years old' has been getting recurrent cough' cold and whee%ing with fever since 8oining the #re#he as well. ,e also starts whee%ing when e7'osed to #igarette smoke or his visit to his farmhouse.
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A#ute e'isode
+)ygen Cin severe casesD Treat with inhaled or oral bronchodilators depending on severity. @2 agonists are main stay of therapy Ese steroids early' particularly if personal 7 family history of atopy present
Multi%trigger whee4er
Management
1f recurrence on stopping' label and treat as asthma LT6A - a less effective alternative
Management Goals
-reedom from
PEP Talk
,ym'toms including nocturnal cough A#ute asthma atta#ks *mergen#y doctor7hospital (isits
Minimal need for relie(ers Minimal ad(erse effe#ts from drugs Normal
Management strategy
Identify and a(oid triggers )se controllers Treat acute attac s with 6elievers *du#ate family regarding management Monitor and modify therapy to maintain control
+e#a'itulating
#lini#al e(aluation
Ascertain diagnosis 1dentify co-morbid conditions Thin of alternate diagnosis
Grade se(erity
1dentify triggers
Grading se(erity
%#er a period of time
helps to decide regarding need and choice of controller medications for long term control
At a point in time
helps to decide regarding the level of care and drugs for an acute e)acerbation
Grading se(erity
1
Intermitte nt
,ym'toms of airf low o$stru#tion
QI once a wee Q Asym'tomati# and normal $etween atta#ks
FF &ormal diurnal variation . /10 0 in 12" values! 3owest 12" levels are seen on wa%in and hi hest levels about 12 hours later!
Grading se(erity
2
Mild 'ersistent
,ym'toms of airf low o$stru#tion
Q M once a wee but I once a day
Grading se(erity
3
Moderate 'ersistent
,ym'toms of airf low o$stru#tion Peak Night time e7'iratory sym'toms f low 9P*-:
Q &4 - /4 N of personal best Q M !4 N diurnal variation
Grading se(erity
4
,e(ere 'ersistent
,ym'toms Pea Night time of airf low e)piratory sym'toms o$stru#tion flow CP"FD
Q $ontinuous Q Limited physical activity Q Fre5uent
Q I &4 N of personal best Q M !4 N diurnal variation
!uration of sym'toms
,e(erity of sym'toms
,ospitali%ations7 1$E
Asthma
Treatment
A(oid triggers ,te' A % Intermittent 1nhaled 7 oral short acting @2 agonists as re5uired ?o controllers
Asthma
Treatment
A(oid triggersG Treat a#ute e'isodes ,te' > % Mild Persistent Preferred treatment 9
Asthma
Treatment
A(oid triggersGTreat a#ute e'isodes ,te' H % Moderate Persistent Preferred treatment 9
Low dose 1$* P inhaled LABA Medium dose 1$* Cin children I ; yearsD
Alternati(e treatment9
Asthma
Treatment
A(oid triggersG Treat a#ute e'isodes ,te' D % ,e(ere Persistent Preferred treatment 9
,te' H B Add LABA ,te' > % Low dose 1$* ,te' A % *A @2 agonists prn
;istory % re#a'
& year old Arpit was seen for recurrent cough since about 3 year. +n en5uiry' the cough bothered him once every two months lasted for three to four days. The cough was much more in the early morning hours.
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Grading se(erity
C%&'R%((ERS ))
%r
&% C%&'R%((ERS ))
'hat is the question*
No #ontrollers
Intermittent asthma
Asthma
Treatment 9re#a'11:
,te' A % Intermittent 1nhaled 7 oral short acting @2 agonists as re5uired ?o controllers A(oid triggers
Clini#al e(aluation1
Ascertain diagnosis 1dentify co-morbid conditions Thin of alternate diagnosis 2rade severity
Identify triggers
Triggers 5 're#i'itants
Allergens Irritants Pre#i'itants
PEP Talk
(iral infections
Inhaled aller ens4 irritants and viral in#ections are the most important tri ers
Irritants
,moke
PEP Talk
Avoid to$a##o smoke' agar$attis' fumes from kerosene sto(e' wood' cow dung
-ine dust
,trong odors
#oils
Allergens
!ust mite antigen
PEP Talk
6emove #ar'ets 5 u'holstery Cotton sheets rather than woolens. ")pose mattresses to sunlight "ash soft toys periodically
Co#kroa#h antigen
Allergens
Molds and s'ores
Pets
climate8> as ed the an)ious granddad. =Khat food stuffs should we avoid8> as ed the grandma.
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PEP Talk
)iet . over.emphasi5ed ,,, 6 eneral avoid list to all patients is irrational!
Ar'it #ontd
A year later' Arpit<s parents stated that he was whee%ing a lot more often. ,e needed the reliever puffs more than twice a wee .
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Gradation of se(erity
6sthma is a dynamic condition! 6t presentation, asthma se#erity is raded to uide introduction o# medication! 7n therapy, the titration o# medications is based on the assessment o# asthma control!
)n#ontrolled
Chara#teristi#
!aytime sym'toms .imitations of a#ti(ities
?one Ctwice or less7wee D ?one
Need for relie(er5 res#ue treatment .ung fun#tion 9P*or -*JA: *7a#er$ations
More than twice7wee I /4N predicted or personal best Cif nownD +ne or more7yearR
?one
)n#ontrolled
Chara#teristi#
!aytime sym'toms .imitations of a#ti(ities
?one Ctwice or less7wee D ?one
Need for relie(er5 res#ue treatment .ung fun#tion 9P*or -*JA: *7a#er$ations
More than twice7wee I /4N predicted or personal best Cif nownD +ne or more7yearR
?one
Asthma %treatment
1f control is not achieved with current regimen' then treatment is to be stepped up until control is achieved. 1f asthma is partly controlled' then increase in treatment should be considered subJect to safety and cost
Ar'it#ontd
Arpit is 'artly #ontrolled.
,e needs stepping up of therapy Cfrom step A to step >D ,e now needs regular controller therapy.
Asthma
Treatment 9re#a':
A(oid triggersG Treat a#ute e'isodes ,te' > % Mild Persistent Preferred treatment 9
,an8ana
*anJana is a A year old who weighs 23 g. *he has been hospitali%ed for whee%ing at least thrice in the last & months and has had fre5uent midnight visits to the "6. *he has been referred to you after an acute episode and is not receiving any interval therapy.
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Asthma
Treatment 9+e#a':
A(oid triggersG Treat a#ute e'isodes ,te' H % Moderate Persistent Preferred treatment 9
Low dose 1$* P inhaled LABA Medium dose 1$* Cin children I ; yearsD
Alternati(e treatment9
,an8ana 11 #ontd
*anJana followed up # wee s later. *he was not better. 1 wondered whyH =Kho gives the medicines to *anJana> 1 as ed her mom8 =1 taught her initially> she replied =now she is old enough to ta e them on her own>. =Are you8> 1 as ed *anJana. *he coyly loo ed away000
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PEP Talk
Enintentional
Forget treatment Poor supervision Misunderstand regimen Enable to use delivery system "mpty canister
,an8ana#ontd
*he was seen si) wee s later. *he was now adherent and the mother was supervising therapy. *he still wo e the night coughing and whee%ed fre5uently.
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The !Ds
Dose Device Delivery
Triggers
Adherence
Functional
The !Ds
Dose Device Delivery
Triggers
Adherence
Functional
Asthma
Treatment 9+e#a'11:
A(oid triggersG Treat a#ute e'isodes ,te' D % ,e(ere Persistent Preferred treatment 9
,te' H B Add LABA ,te' > % Low dose 1$* ,te' A % *A @2 agonists prn
A$$as
Abbas is a . year old boy with moderate 'ersistent asthma on therapy. ,e reported a nocturnal cough and snee%ed every morning. ,is mother was regular with the inhalers and the techni5ue was appropriate as chec ed in the clinic.
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Allergi# rhinitis
Intermittent
I # days per wee or I # wee s
Persistent
T # days per wee and T # wee s
Mild
normal sleep U no impairment of daily activities' sport' leisure U normal wor and school U no troublesome symptoms
Moderate%se(ere
one or more items abnormal sleep impairment of daily activities' sport' leisure abnormal wor and school troublesome symptoms
in untreated 'atients
Allergi# rhinitis
!rugs a''ro(ed for #hildren
To'i#al
?asal steroids
Mometasone furoate U Fluticasone furoate9 T 2 years Fluticasone propionate9 T# years Budesonide T & years
/ral
Antihistaminics
$etiri%ine U Desloratadine9 T & months of age Loratadine9 T 2 years Fe)ofenadine9 T & years
?asal Antihistaminics
A%elastine9 T ; years +lopatadine T 32 yrs
LT6A
Montelu ast9 T & months of age.
Trial of Anti%ref lu7 treatment with PP1 can be given in such cases for /-32 wee s Although recent data has failed to show a therapeutic benefit in children with severe asthma and proven 2"6D. +ral bronchodilators7theophylline to be avoided
-ollow u' 1 1 11
Khenever *anJana' Abbas or Arpit visit your office'
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bronchodilator usage nocturnal symptoms school absenteeism limitation of activity growth monitoring
P arental #on#erns
+egimen prescribed
+n a subse5uent visit' *anJana<s dad as ed if there was an obJective way of monitoring her. =$ould they predict an attac and start early treatment 8>' he as ed *anJana<s mom had a similar 5uery regarding spirometry0
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Monitoring
"ssentially #lini#al P*-+ if
PEP Talk
Traina$le i.e. age above ; years Tena$le i.e. well initiated to therapy Afforda$le
,'irometry if
Cases
*anJana' Arpit and Abbas ept well on their regimes. +n the ne)t visit' the parents en5uired =what ne)t8>
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reduce 1$* alone by ?LN while continuing LABA. Khen control is maintained reduce 1$* till low dose is reached when LABA can be stopped
,to' controller regimen Trigger a(oidan#e continues "ritten ;ome management 'lan for acute episodes C,te' A regimeD
Follow up H%K monthly for A%> years $ounsel regarding 'ossi$le future resum'tion of controller' if recurrences.
"hat ne7t 3
*anJana stays well. At one of the visits the parents as =1s she now cured8>
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Natural history
PEP Talk
6e-emphasi%e that drugs #ontrol but do not cure' As asthma among children often remits' control can be considered as good as cure. 1dentify those at risk for 'ersisten#e
PEP Talk
-emale *#4ema +nset after age of ! years ,e(ere disease Parental history of atopy 7 asthma
Case
*ailesh is a . year old with mild 'ersistent symptoms. =,e<s in trouble every year between ?ovember and March>' says the mother. 1 confirm this seeing his past records over two years.
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,easonal asthma
Management
*tart a few wee s 'rior to anti#i'ated onset of symptoms continue through the season
Case
Daphin plays interschool bas etball. "very time he starts his game' he is whee%ing within minutes. =Kill 1 be able to play the finals8> he as s an)iously
"ill you let him 'lay and what will you ad(ise him3
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PEP Talk
PEP Talk
$hoice of game ?ose breathing Avoid e)ercise on cold mornings *low deep breathing Karming up
-or #ontrol
*uitable controller regimen Cconsider LT6A7 LABA with 1$*D 1$*P LT6A 7 1$* P LABA 1n addition 9 1nhaled *A @2 agonist - 3;-!4 min before planned e)ercise.
-or treatment
1nhaled *A @2 agonist
Case
Mrs 6eddy had heard of your interest in asthma. *he came you as ing to confirm the diagnosis. *he en5uired whether homeopathy would have an answer. *he had also heard about fish therapyH
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+ela71and e7'lain
PEP Talk
Limited scientific literature on acupuncture' homeopathy Benefits of Voga ?o scientific literature on Gfish therapy< etc Current e(iden#e does not suggest $enefits1
Case11
Mrs *hah brought her / year old. *he had come on a very busy clinic day. Vou 5uic ly tell her the diagnosis and advise her the inhaled steroid regime. *he does not follow up. Vou diagnosed rightC 'res#ri$ed right' but later learn that they have gone to a colleague for a second opinion and are continuing with himH
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+elie(ers
,hort%a#ting >%agonists
*albutamol Terbutaline
Anti#holinergi#s
1pratropium bromide
,teroids Methyl7anthines
C*elect situationsD
Magnesium sul'hate
Inhaled >%agonists
!rugs of #hoi#e. *albutamol 7 Levo-*albutamol7 Terbutaline are similar. *evere acute episode B nebuliser preferred Dose - 4.3; mg7 g7dose Cminimum dose 2.;mgD or say as rough guideline9 I # years - 4.; ml of salbutamol nebuliser soln
M # years - 3 ml of salbutamol nebuliser soln
+es#ue ,teroids
*arly usage - reduces morbidity7 hospitali%ation /ral 'rednisolone 3 mg7 g for !-. days.
,ydrocortisoneC # mg7 gD 5 &hr or 1( Methylprednisolone C3-2 mg7 gD 5&hr 1( 7 1M De)amethasone C4.3 B 4.2 mg 7 WgD 5 & hr
Anti#holinergi#s
I'ratro'ium $romide Additi(e effect to @2 agonist in acute severe asthma Ne$ soln E L1? ml @AyrC AmlBA yr C$ompatible with @2 agonist solution.D Limit use to >D hours to prevent atropine li e effects Ce.g.feverD
Magnesium ,ul'hate
Me#hanism of a#tion 9
acts through a different pathway C calcium channelD in the airway has immediate bronchodilator and mild anti inflammatory effects
>?%?L mg5kg IJ slow infusion dissol(ed in ?L ml ,aline o(er HL minutes 9total ma7imum dose%>g:
!ose9
To7i#ity I
Amino'hylline
6etains its role as reliever in acute severe attac s
!ose9
Loading dose ; mg7 g B slow diluted IJ $olus with ?M !e7trose CAvoid if patient on *6 theophyllineD Followed by 4.;B3.4mg7 g7hr as infusion CAvoid subse5uent bolus dosesD
To7i#ity
/7ygen
Maintain *a+2 M A2N.
@Bagonists may parado)ically worsen hypo)ia Initially use oxy en to nebulise 82 a onists
Case11
Arpit decides to help his mother with Diwali cleaning. ,e starts coughing continuously soon after and his mother rushes him to the clinic0
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Duration 8 6elievers ta en8 - 6esponse8 Brittleness C6apid worseningD $ontroller7 trigger factors +n regular controller8 ?umber and severity of previous attac s Last theophylline dose Cif relevantD
Case #ontd
+n e)amination' Arpit has a respiratory rate of #& per minute and a mild increase in accessory muscle activity. ,e appears comfortable and is able to tal in sentences. Auscultation reveals a whee%e towards the end of e)piration.
;ow will you grade Ar'its a#ute atta#k and manage him3
Grading se(erity
%#er a period of timehelps to decide regarding need and choice of controller medications for long term control
At a point in time helps to decide regarding the level of care drugs for an acute e)acerbation and
"hee4ingF
?one Terminal e)piration with stethoscope "ntire e)piration with stethoscope During inspiration and e)piration without stethoscope
2 !
#&B&4 M &4
!&B;4 M ;4
,#ore
;ome management
P, N H 9mild grade:
*A @2 agonist9 2 - # actuations through MD1 P spacer P mas 6epeat every 3; - 24 mins for ma) ! times 1f response ill sustained CI # hrsD' start 3st dose of rescue steroid
Case11
*anJana calls you in the middle of the night. *he is proceeding to the casualty once again. Vou rush in to see her and find her to have a respiratory rate of #4 per min. *he has suprasternal recessions and auscultation reveals whee%e throughout e)piration.
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"hee4ingF
?one Terminal e)piration with stethoscope "ntire e)piration with stethoscope During inspiration and e)piration without stethoscope
2 !
#&B&4 M &4
!&B;4 M ;4
,#ore
* +oom 'lan
P, D%K 9moderate:
+2 *A @2 agonist
?ebulised 5 24 min ) ! or MD1 P spacer P mas 2 puffs 5 2 min or so till & puffs reached. 2ive & puffs li e this 5 24 min in the first hour. or Cif inhaled therapy not availableD Terbutaline single dose7Adrenaline 4.43mg7 g sc 5 24 min ) !
$ommence 7 $ontinue rescue steroid $ontinuous assessment for #-& hours 1f good responseCP* I!D' decrease nebulisation to !-# hourly
*anJana does not respond to this treatment. +ne hour later' her respiratory rate has gone up to ;4 per minute. Vou decide to admit her to the ward. =Khat do we do ne)t8> as s your resident doctor
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"ard 'lan
$ontinue +)ygen' 1(7oral steroid *tart 1( fluids *A @2 nebuli%ation - hourly7 bac -to-bac 1pratropium neb 5 24 min ) ! and then 5 & hours Monitor *a+2 and serum WP $B$' Y-6ay chest only to identify complications Pulmonary score 5 3;-!4 minutes
Vour resident doctor is new but means well. =Khat complications should 1 e)pect8> he as s and =*ir7Madam' no antibiotics8 > he continues with a bewildered loo .
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Com'li#ations
Atelectasis *econdary infection Pneumothora) Pneumomediastinum *ubcutaneous emphysema Therapy related
+ole of anti$ioti#s
Limited role $onsider only in those with
purulent secretions and radiological evidence of pneumonia.
er asthma
Case
!& hours later *anJana is showing signs of improvement. +n your morning round' you find her sitting up comfortably sipping her tea. *he says she slept well through the night. +n e)amination she is mildly tachypnoeic and her whee%e is now only in the terminal phase of respiration. =$an 1 go home8> she as s
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Discontinue terbutaline 7aminophylline drip in 2# hours Discontinue ipratropium neb in 2# hours 6educe *A @2 agonist to 5 2-# hrly and then 5 #&hrly 6eplace iv steroid with oral steroid
!is#harge #riteria
Pulmonary score I ! *lept well at night Feeding well Appears comfortable. ?ot on any continuous infusions and receiving less fre5uent 2 agonists Csay & hourlyD
Cases1 #ontd
"hat will you ad(ise Ar'it and ,an8ana when they are ready to go home3
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!is#harge 'lan
1nhaled *A @2 agonist MD1 P spacer P mas 5 #-& hour till symptoms abate $ontinue course of rescue steroid for !-. days CTapering not necessaryD "ducate regarding home plan 7 long term strategy Plan follow up visit within .-3# days 6eview compliance' trigger elimination' controller regime
Case1
Meanwhile' 6aJu' a / year old with asthma is brought to the hospital in an ambulance with o)ygen by mas . ,e is too $reathless to s'eak' is sweating and 5uite agitated. +n e)amination his nails are dusky and on auscultation you hardly perceive any air entry. ,e has shown no response to ! doses of nebuli%ed bronchodilator given while he was rushed in with sirens blaring.
interact !
Asthma
P+ed f lag signs
Enable to tal or cry $yanosis Feeble chest movements Absent breath sounds Fatigue or e)haustion Agitated Altered sensorium +)ygen saturation I A2N
Treat or +efer3
+2 to be continued but monitor *a+2 1nJ adrenaline 7 terbutaline sc 1nhaled 2 agonist P 1pratropium to be started 1nJ *teroids and iv fluid therapy Arrange proper transport to 1$E
IC) 'lan
$ontinue 7 initiate intensified ward plan Blood gas studies Possible intubation and mechanical ventilation with etamine and mida%olam 7 fentanyl iv infusion Paralysis with vecuronium' if re5uired
To summari4e
!iagnosis
Asthma is an inflammatory illness Diagnosis of asthma is clinical' and relies on history All asthma does not whee%e 1n children I ? yrs' consider differential diagnosis before labelling Many children outgrow their asthma A family history of asthma 7 atopy increases ris of asthma
To summari4e
.ong term management
Patient education is a very important part of asthma management Drugs control' but do not cure asthma $linical grading over time' decides long term management plan 1ntermittent asthma does not merit controllers 1nhaled steroids are mainstay of long term asthma management Treatment should be stepped up or stepped down depending upon patient response
To summari4e
A#ute management
2rading at a point in time decides management *A inhaled @2 agonists are used to manage acute e)acerbations Fre5uent use of *A @2 agonists indicate poor control of asthma
!e(i#es
+a8u Qhu$#handani +! Qhare A8it Ga8endragadkar ,ailesh Gu'ta 9.ate: Ritu Jora Indu Qhosla !a'hin -ernandes
*o *hivbalan * W Wabra 6aJu Whubchandani *hishir Moda (arinder *ingh *ubhasis 6oy Pallab $hatterJee *uresh babu T E *u umaran ? W *ubramanya
!r1 ,1 Naga$hushana'
$oordinator' ATM ' 1AP 6espiratory chapter
And team
Idea
T E *u umaran *achidananda Wamat *wati Bhave
*pecial than s
Academic grant from