CPG for Asthma & COPD

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CPG for Asthma & COPD

  1. 1. 1 EVALUATION GUIDELINE ASTHMA & COPD Asthma COPD Obstructive Asthma & COPD Pathophysiology COPD Asthma COPD Asthma Airways affected  Alveolar  Destruction(Emphysema)  Bronchiolitis  Fibrosis  Large and small  No emphysema  Mucus plugs  Bronchial Hyper Responsiveness Inflammatory Cells  Neutrophils  Macrophages  CD8,Tcells  Eosinophils  Mast cells  CD4,T cells Mediators  IL-8, TNF alpha,LTB4  Reactive Oxygen species  IL-4,IL-5,cysLTs  Histamine Airway Obstruction  Irreversible  Reversible COPD Asthma COPD Asthma  Onset in mid-life  Symptoms slowly progressive  Long history of tobacco smoking  Dypnea during exercise  Largely irreversible airflow limitation  Onset early in life (often childhood)  Symptoms vary from day to day  Symptoms at night / early morning  Allergy, rhinitis, and or eczema also present  Family history of asthma  Largely reversible airflow limitation
  2. 2. 2 ASTHMA 1. 2. 3. (noctural asthma) 4. 5. atopy skin eczema 6. 7. wheeze 1. 2. 3. 4. 5. 6.
  3. 3. 3 - COPD - Acute pulmonary edema - Foreign body aspiration - Gastro-esophageal reflux - Bronchiectasis - Upper airway obstruction (Spirometry) Reversible airflow obstruction FEV1(forced expiratory volume in one second) 12 FEV1 200ml. PEF 60 / 20 Reversible airflow obstruction Spirometry Spirometry 20 ,Aspirin induced asthma Spirometry COPD Spirometry COPD
  4. 4. 4 (variable) PEF 1-2 20 PEF variability = (PEFmax-PEFmin)x100 ½(PEFmax + PEFmin) PEF variability PEF 1 PEF PEF PEFmin x100 PEFmax variability (bronchial hyper responsiveness) FEV 1 methacholine (methacholine challenge test) 1. (allergen) 2. 3. 4. NSAIDs (aspirin) B-blockers
  5. 5. 5 5. 6. 7. 8. Allergic rhinitis 1. corticosteriod I ntermittent Persistent asthma Spi rometry 1 Intermittent 1 PEF 2 PEF FEV1 ≥80% PEF variability <20% 2 1 1 2 PEF FEV1 ≥80%
  6. 6. 6 Mild persistent PEF variability < 20%- 30% 3 Moderate persistent 1 PEF FEV1 60%-80% PEF variability >30% 4 Severe persistent PEF FEV1 ≤ 60% PEF variability >30% 2. (controller) Asthma Control Test(ACT) Asthma Control Questionnaire(ACQ) 3 (controlled)
  7. 7. 7 (Relivers) (Partly controlled) (uncontrolled) Controlled ( ) Partly Controlled ( ) Uncontrolled 2 2 Partly controlled 3 Partly controlled 3 Partly controlled 3 Reliver/rescue 2 2
  8. 8. 8 treatment Partly controlled 3 ( PEF or FEV1) 80%pre dicted or personal best Partly controlled 3 (Exacer bation) 1 1 Controller Medications Inhaled Glucocortico steroids -Beclomethasone -Budesonide -Fluticasone propionate inflammat ory cell mic rovascular leakage 2- agonists Local side effect -Oropharyngeal -candidiasis(Oral thrush) -Dysphonia -Cough Systemic side effect( ) - -Osteoporosis - first choice persistent asthma inflammat ion spacer Leukotriene modifiers LT-receptor antagonist -Montelukast -Zafirlukast 5-lypoxygenase Headache,fatique aspi rin-sensitive asthma I CS
  9. 9. 9 inhibitor -Zileuton LABA Long-acting inhaled β2- agonists -Salmeterol - Formoterol( duration ) - stero ids - mucocilia ry clearance - vascular permeability -CVS stimulants (Tachycardia) -Hypokalemia Skeleton muscle tremor ICS ICS Long-acting oral β2-agonists -Salbutamol(slow release formulation) -Terbutaline(Slow release formulation) -Bambuterol - stero ids - mucocilia ry clearance - vascular permeability IC S Theophylline SR Theophylline SR Th eophylline mucoc illary clearance Arrythmia Tachycardia Seizures (10-20 mcg/ml.)meta bolite Cyp1A2 Cyp1A2 inhibitor Cimetidine Erythromycin
  10. 10. 10 Ciprofloxacin Cyp1A2 inducer Rifampicin Phenytoin Carbamazepi ne Phenobarbital Systemic glucocorticoi ds -Prednisolone -Methyl prednisolone -Hydrocortisone -Dexamethasone inflammat ory cell mic rovascular leakage 2- agonists Fluid retention HPA axis Osteoporosis ( 3- 10 ) (>2 ) Anti-IgE Omalizumab monoclo nal antibody IgE Pain and bruising Anaphylaxis 12 SC ICS Cromones Sodium cromoglycolate mild persistent
  11. 11. 11 Reliver Medication Rapid-acting inhaled β2-agonists -Salbutamol -Terbutaline -Fenotero -Procaterol -Formoterol Lo ng acting inhaledβ2- agonists steroids mucocilary clearance vascular permeability Long acting inhaled β2- agonists CVS stimulants Hypokalemia Skeleton muscle tremor duration (Re gular controller) ICS Short acting oral β2-agonists -Salbutamol -Terbutaline -Procaterol Lo ng acting inhaledβ2- agonists steroids mucocilary clearance vascular permeability Inhaled -Ipratropium
  12. 12. 12 anticholinergics bromide vagal tone (bitter taste) inhaled β2- agonists Short acting theophylline -Theophylline Anhydrous -Aminophyline anhydrous -Aminophyline dihydrate respiratory drive 2-agonists Arrhythmia Tachycardia Seizures - Theophylline 100% - Theophylline 86 % - Theophylline 79% Systemic glucocorticosteroid s Prednisolone inflammatory cell microv ascular leakage 2- agonists Fluid retention HPA axis Osteoporosis 40- 50mg. 5-10 Easyhaler Beclomet Easyhaler inhalation powder Beclomethasone dipropionate 200mcg/dosex200 doses Turbuhaler Pulmicort turbuhaler Budesonide100mcg/dosex200doses Budesonide200mcg/dosex100doses
  13. 13. 13 Turbuhaler Symbicort Forte turbuhaler Budesonide320mcg,Formoterol fumarate 9 mcg/dosex60doses Turbuhaler Symbicort turbuhaler Budesonide160mcg,Formoterol fumarate dihydrate4.5mcg/dosex60doses Turbuhaler Symbicort turbuhaler Budesonide80mcg, Formoterol fumarate dihydrate4.5mcg/dosex60doses Evohaler Flixotide evohaler Fluticasone propionate125mcg/dosex120doses Fluticasone propionate250mcg/dosex60doses Evohaler Seretide25/125 evohaler Salmeterol 25mcg,Fluticasone propionate 125mcg/dosex120dose Evohaler Seretide25/250 evohaler Salmeterol 25mcg,Fluticasone propionate 250mcg/dosex120dose Evohaler Seretide25/50 evohaler Salmeterol 25mcg,Fluticasone propionate 50mcg/dosex120dose Accuhaler Seretide50/100 accuhaler Salmeterol50mcg,Fluticasone propionate 100mcg/dosex60dose Accuhaler Seretide50/250 accuhaler Salmeterol50mcg,Fluticasone propionate 250mcg/dosex60dose Evohaler Ventoline evohaler Salbutamol sulfate 100mcg/1 inhalationx200doses Evohaler Combivent metered aerosol Salbutamol sulphate120mcg,Ipratropium Bromide monohydrate21mcgx200doses/10mlx1”s Turbuhaler Bricanyl turbuhaler Terbutaline sulfate0.5mg/1dosex200doses Evohaler Berodual metered dose inhaler Fenoterol HBr 0.05mg,Ipratropium Br0.02mgx200puff/10ml.
  14. 14. 14
  15. 15. 15 1 As need reliever medicatio n Rapid acting β2-agonist ( ) 2 Reliever medicatio n plus single controller Rapid acting β2-agonist + Low dose ICS 3 Reliever medicatio n plus one or two controller Rapid acting β2-agonist + Low dose ICS + Long actingβ2-agonist Steroids ( dose steroids medium or high) Rapid actingβ2-agonist+Medium or high dose ICS ( Long actingβ2-agonist) 4 Reliever medicatio n plus two or more controller Rapid acting β2-agonist+ Medium or high dose ICS+Long acting β2-agonist 5 Reliever medicatio n plus additional controller options ( 4)oral glucocorticoid (lowest dose) / anti- IgE treatment
  16. 16. 16 1. 2. NSAIDs beta blockers 3. 4. peak flow meter 5.
  17. 17. 17 COPD (Chronic Obstructive Pulmonary Disease) COPD (usually progressive) noxious agent (abnormal inflammation) noxious agent Allergen Atopy COPD 2 (Chronic bronchitis) (emphysema) Emphysema ( )
  18. 18. 18 alveoli Chronic bronchitis ( ) 3 1 2 COPD 1.Gene 1-antitrypsin Protein Neutrophils esterase Neutrophils Neutrophil esterase 1- antitrypsin Neutrophils esterase elastin 2.Exposure to particles  Tobacco smoke  Occupational dusts,organic and inorganic  Indoor air pollution from heating and cooking with biomass in poorly vented dwellings  Outdoor air pollution  Lung growth and development  Oxidative stress  Gender  Age  Respiratory infection
  19. 19. 19  Previous tuberculosis  Bronchial hyperesponsiveness 
  20. 20. 20
  21. 21. 21
  22. 22. 22
  23. 23. 23 Figure 2 Spirometric Classification of COPD Severity Based on Post-Bronchodilator FEV1 Stage I : Mild FEV1/FVC < 0.70 FEV1 ≥ 80% predicted Stage II : Moderate FEV1/FVC < 0.70 50% ≤ FEV1 < 80% predicted Stage III : Severe FEV1/FVC < 0.70 30% ≤FEV1<50% predicted Stage IV: Very Severe FEV1/FVC <70% FEV1 < 30% predicted or FEV1 < 50% Predicted plus chronic respiratory failure Spirometry 0.5,1,2 3 Spirometer Spirogram
  24. 24. 24 FVC(forced vital capacity) (TLC=total lung capacity) FEV1 (forced expiratory volume time) (TLC) 1,2,3 FEV1 FEV2 FEV3 FEV1/FVC % FEV1 FVC FEV1/FVC%,FEV2/FVC%,FEV3/FVC% COPD 1. 2. 3. 4. 5. 6. COPD Bronchodilator steroids FEV1
  25. 25. 25 Bronchodilator 2-agonist,anticholinergic,theophylline combination side effect onset side effect
  26. 26. 26  2-agonist Short acting : Salbutamol,Terbutaline,Fenoterol=duration 4-6 prn.
  27. 27. 27 Long acting : Salmeterol,Formoterol,Bambuterol =duration 12 bid.  Anticholinergic ( COPD ) Short acting : Ipratopium bromide = duration 6-8 qid Long acting : Tiotropium bromide = effect 72 = DPI theophylline  1.Influenza vaccine Pneumococcal vaccine 2.Alpha1-antitrypsin 3.Mucolytic 4.Antibiotic 5.Oxygen treatment O2 long term ( 15 ) 6.Antioxidant N-acetylcysteine ROS( steroids)  1. (Pulmonary rehabilitation)  spirometry   
  28. 28. 28   1. (endurance exercise) exercise perfomance 20 3 70 ( 220- )   pursed-lip 5 
  29. 29. 29  8 (6-minute walk test) performance score 2. 15 lung mechanics PaO2 60 mmHg. SaO2 90% 1 (Smoking cessation) FEV1 5 ”5A” 1.Ask about tobacco use ( )
  30. 30. 30 2.Advise to quit( ) 3.Assess willingness to quit ( ) 2- 3 5R”s  Relevance  Risks  Rewards  Roadblocks  Repetition 4.Assist in quit attempt( )
  31. 31. 31 nicotine dopamine dopamine  Nicotine replacement therapy  Bupropion Sustained- release norepinephrine,serotonin dopamine 5.Arrange follow up Pressure metered-dose inhaler (PMDI) 1. 2. 4-5 3. 2 MDI 2 MDI 4 4. MDI 1- 2 aerosol
  32. 32. 32 30l./min. 3- 5 5. MDI 10 6. 1-2 7. 8. 9. 4 Turbuhaler 1. Turbuhaler 2. 1 dose “ ” 3. Mouthpiece Turbuhaler 4. Mouthpiece Turbuhaler
  33. 33. 33 5. Turbuhaler 6. 7. 4 Accuhaler 1. accuhaler 2. “ ” accuhaler 3. accuhaler accuhaler 4. accuhaler
  34. 34. 34 “ ” 6. 7. 4 Handihaler 1= Mouthpiece Handihaler
  35. 35. 35 2=Mouthpiece 3= Handihaler 4= 5= capsule 1. 1 Handihaler Mouthpiece 2. 3. Mouthpiece “ ” 4.
  36. 36. 36 5. Mouthpiece Handihaler 6. Mouthpiece handihaler
  37. 37. 37

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