Asthma & COPD | Jindal Chest Clinic

1. Bronchial Asthmaand Chronic Obstructive Pulmonary Disease (COPD)

2. Asthma Chronic Inflammatory (allergic) disorder of airways, characterized by Episodic, Reversiblebronchospasm (i.e narrowing of airways) and airway responsiveness resulting from an exaggerated broncho-constrictor response to various stimuli (triggers)

3. Epidemiology • Common disease at all ages • Prevalence Adults 2-5% Children Up to 10 % Total global burden App 300 millions • Expected by 2025: 100 m. additional • Loss of DALYs : About 15 m./year (around 1% of all DALYs lost) • Accounts for 1 in every 250 deaths • Considerable economic costs

4. INDUCERS Allergens,Chemical sensitisers, Air pollutants, Virus infections Airway Hyperresponsiveness Genetic* Airflow Limitation TRIGGERS Allergens, Exercise, Cold Air, SO2 Particulates SYMPTOMS Cough Wheeze Dyspnoea Asthma Pathophysiology INFLAMMATION

5. Lumen Mucosa Muscle Muscle hypertrophy Mucosal inflammation, edema Airway narrowing Mucus plugging Mucus gland hypertrophy

6. Causes of Asthma • Hereditary presence of atopy (allergy) • Environmental triggers/ causes Infections House dust mites, other insect products Pollens of grasses and trees Dusts and smokes Chemical vapours

7. Misc. Risk Factors for Asthma • Presence of allergic rhinitis or other allergies • Gastroesophageal reflux ? • Obesity ? • Exercise • Cold climate • Drugs and chemicals • Other occupational exposures • Psychological factors • Allergic bronchopulmonary aspergillosis • Tobacco smoking

8. Indoor Air Pollution • Biomass Fuel Combustion • Environmental Tobacco Smoke (ETS) • Others: Environmental Biological (bacterial, fungal) Construction related Consumer products House dust (etc.)

9. Factors influencing atopy • Allergen exposure • Dose of allergens • Infections and infestations – may promote or suppress an IgE response • Nutrition: Variable Obesity – Higher incidence Cod liver oil – widely recommended Vit. B12, Vit. C, nicotinic acid Selenium - ? protective

10. Aggravating Factors (GER) • Old age • Autonomic dysfunction – lowering of lower esophageal sphincter tone • Gastroesophageal regurgitation, hiatus hernia • Medication: Beta blockers, other anti-hypertensive drugs

11. Asthma - triggers • Home environment • Aero allergens • House dust (mites/others) • Tobacco smoke (ETS) • Solid fuel smoke • Infections • Outdoor exposures: SO2, Ozone • Occupational exposures • Psychological stresses • Drugs: aspirin, betablockers, ACE inhibitors

12. Pollen House-dust Mite

13. Diagnosis • Clinical Features Symptoms and triggers • Physical Examination • Investigations

14. Clinical Feature of Asthma • Generally episodic, and seasonal • In some patients, continuous • Mild and intermittent to severe and persistent forms • Common symptoms: Cough, chest tightness, wheezing and breathlessness; expectoration. • Early morning attacks • Associated nasal symptoms: Sneezing, rhinorrhoea, nasal blockade; URC

15. Physical Examination GPE during an attack: Tachypnoea, Chest hyper-inflated, P. Note hyper-resonant; Breath sounds decreased Wheezing/ rhonchi If severe: Respir distress, cyanosis (rare), shock; pulsus paradoxus etc.

16. Investigations Chest X-Ray: Normal or signs of hyperinflation; pneumothorax; lobar collapse, consolidation Demonstration of Variable air-flow obstruction Low PEF; Reduced FVC, FEV1/FVC, PEF diurnal variations, Bronchodilator reversibility Airway hyper-responsiveness Biochemical investigations

17. Airway inflammation: Blood and sputum eosinophilia Exhaled air nitric oxide levels Bronchial mucosal biopsy Presence of atopy Serum IgE levels Demonstration of specific antibodies Skin hypersensitivity tests

18. Differential Diagnosis • Chronic obstructive pulmonary disease • Upper respiratory catarrhs • Hyper-sensitivity pneumonias • Hyper-eosinophilic syndromes • Bronchiectasis Children: Acute laryngotracheo-bronchitis, bronchopneumonia, cystic fibrosis Foreign body aspiration

19. All that wheezes is“Not Asthma”andAll asthmadoes not wheeze

20. The Overlap COPD Asthma Neutrophils Eosinophils No airway hyperresponsiveness Wheezy bronchitis 10% Airway hyperresponsiveness Less bronchodilator response Bronchodilator response Steroid response Limited steroid response

22. Asthma-like syndromes • Exercise-induced asthma • Occupational asthma • Hyper-sensitivity pneumonia • Eosinophilic bronchitis • Eosinophilic syndromes • Obesity-hypoventilation syndromes • Drugs and diets

23. Complications • Acute exacerbations • Acute respiratory failure • Pneumothorax, pneumomediastinum, sub-cutaneous emphysema • Respir infections, pneumonias • Allergic broncho-pulmonary aspergillosis • Airway remodelling, irreversible obstruction • Tmt related complications: Local, systemic

24. Allergic Broncho Pulmonary Aspergillosis Hypersensitivity to aspergillus in the tracheo-bronchial tree in patients with chronic asthma. Clinical Features: Severe attacks, sputum production; hard brown plugs; hemoptysis Radiology: CXR and HRCT: Fleeting opacities, typical patterns; bronchiectasis Diagnosis: Skin test: Immediate & delayed +ve Sputum for aspergillus +ve Serology +ve; Total & Aspergillus specific IgE levels

25. Goals of Asthma Management • Minimal (ideally no) symptoms • Minimal (or no) symptoms on exercise • Minimal need for relievers • No exacerbations • No limitation of physical activity • Normal (or near normal) PFT • Minimal side effects of drugs • Prevention of irreversible obstruction • Prevent asthma related mortality

26. INDUCERS Allergens,Chemical sensitisers, Air pollutants, Virus infections Airway Hyperresponsiveness Genetic* Airflow Limitation TRIGGERS Allergens, Exercise, Cold Air, SO2 Particulates SYMPTOMS Cough Wheeze Dyspnoea Asthma Pathophysiology INFLAMMATION

27. Targets for Treatment(Based on pathophysiology) 1.Symptom Treatment: Cough Wheeze, Dyspnoea Treatment of Airflow Limitation 2. TREATMENT OF INFLAMMATION 3. Management of Airway Hyper-responsiveness 4. MANAGEMENT OF INDUCERS & TRIGGERS • Allergens, Chemical sensitizers, Virus infections Air pollutants, Allergens, Exercise, Cold Air, SO2 Particulates 5. Genetic manipulation?

28. Anti-asthma drugs Bronchodilators (Relievers) Primary action on bronchial smooth muscles, relieve bronchospasm, produce symptomatic relief Anti-inflammatory drugs (Controllers) Reduce inflammation, improve airflow, reduce AHR, prevention of recurrent symptoms, prolonged relief

30. Bronchodilators (Relievers) 1. Theophyllines 2. Sympathomimetics Beta agonists (Selective) Rapid acting  2 agonists(Salbutamol, Terbutaline) Long acting (Salmeterol, Formoterol) Oral short acting 2 agonists 3. Anticholinergic/ muscarinic agents) Inhaled anticholinergics 4. Oral glucocorticoids

31. Anti-inflammatory Drugs • Corticosteroids: Inhaled (Beclomethasone, Budesonide, Fluticasone, Mometasone, Triamcinalone) Oral (Prednisone, Prednisolone, Dexamethasone, Methylprednisolone) Parenteral (Hydrocortisone, Methylprednisolone, Dexamethasone etc) • Immunosuppressants • Immunomodulators

32. Inhalational Treatment Preferred route for both controller and reliever therapy Advantages: Local effect, immediate response Minimal dosage, few side effects Available as : Dry powder (DPIs), Metered dose liquid inhalers MDIs); Nebulizers Devices: Spacers (to increase drug delivery)

33. Side effects of inhalation drugs Local side effects: throat irritation, voice change, thrush (candida infection), vocal cord dysphonia Systemic side effects of drugs: Rare may be growth retardation in young children cataracts, other steroid effects

35. Metered Dose Inhalers

36. Dry powder inhalers

37. Managing Aggravating Factors • Tmt of sinusitis and polyps • Managing GE reflux • Weight reduction • Sleep disorder evaluation • Tmt of psychological stress • Management of VCD if any • Reducing allergen load, dust, smoke/ETS, pets (etc.)

38. Acute severe asthma • Unable to complete a sentence in one breath • RR > 30/minute • Use of accessory muscles of respiration • HR > 120/minute • Pulsus paradoxus > 25 mm Hg • Extensive inspiratory and expiratory wheeze • PEFR < 50% personal best • PaO2 < 60 mm Hg, PaCO2 > 45 mm Hg GINA 2004

39. Management of severe asthma • Stabilization: Oxygen, hydration • Nebulized bronchodilators • Oral/ parenteral corticosteroids • Evaluate and treat confounding or exacerbating factors 5. If refractory to treatment, assisted ventilation may be required.

40. Difficult situations Maintenance treatment • Labile/Brittle asthma • Steroid dependent • Other comorbidities Specific situations • Pregnancy • Surgery • Concurrent diseases and drugs • Occupational asthma

41. Prognosis • Good, unless poorly controlled, severe and continuous with frequent exacerbation • Compatible with normal life span and quality of life. Too many restrictions must be avoided. • Irreversible airway obstruction in some with poor control – remodelled asthma • Some phenotypes of asthma are associated with risk of fatality – Brittle asthma, Near fatal asthma, Steroid dependent asthma.

42. SUMMARY Asthma is a common and important health problem at all ages, especially during childhood. It is characterized by an atopic state, airway hyper-responsiveness, obstruction, wheezing and breathlessness. Asthma has a genetic basis, but precipitated by multiple triggers such as allergens, infections and other agents. It is important to look for triggers/ causes of asthma for an effective control. Airway inflammation, a prominent feature in asthma, needs to be targeted with effective anti- inflammatory medication (primarily inhalational) to achieve asthma control.