








A chronic inflammatory disorder of the
airway
Infiltration of mast cells, eosinophils
and lymphocytes
Airway...
Predisposing Factors


Atopy

Causal Factors


Indoor Allergens







Outdoor Allergens





Domestic mites
Ani...
Environmental
factors

Mucosal inflammation
Atopic
sensitization
Phenotype

Genetic factors
Structural changes
1.

Extrinsic or allergic:







1.

History of `atopy` in childhood
Family history of allergies
Positive skin test...
CLASSIFY SEVERITY

STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent
STEP 1
Intermittent

Clinica...


GINA Guideline clearly states that THERE
IS NO CURE FOR ASTHMA, But
appropriate management most often
leading to CONTRO...





Relievers
Preventers
Peak Flow meter
Patient education
-

Rescue medications
Quick relief of symptoms
Used during acute attacks
Action lasts 4-6 hrs








Short acting β 2 agonists
Salbutamol
Levosalbutamol
Anti-cholinergics
Ipratropium bromide
Xanthines
Theophylli...
Selective β2 agonist

ATP
cAMP

Relaxation
Theophyline

5’-AMP

Ipratopium
Ach

Vagus nerve
-

Prevent future attacks
Long term control of asthma
Prevent airway remodelling
Corticosteroids
Prednisolone, Betamethasone
Beclomethasone, Budesonide
Fluticasone
Long acting β2 agonists
Bambuterol, Sal...
SALBUTAMOL INHALER
100 mcg:
1 or 2 puffs as necessary
LEVOSALBUTAMOL INHALER
50 mcg :
1 or 2 puffs as necessary


Formoterol ( fast relief and sustained
relief ) +



Budesonide ( twice or even once
daily use )
Dose: 1- 4 puffs ( OD...


Metered dose inhalers



Dry powder inhalers

(Rotahaler)


Spacers / Holding chambers
Dry Powder
Inhaler

Metered Dose inhaler

Spacer








Step I: When symptoms are less than once daily occasional inhalation of a short acting Beta-2 agonist –
salbut...
allergen
allergen
avoidance
avoidance

indicated
indicated
when possible
when possible

pharmacotherapy
pharmacotherapy
sa...
Birth:TH2
Older siblings:
Many infections
[TH1 stimuli]

Allergen
Exposure

TH1
No allergies

Source: Busse WW, Lemanske R...







Patients diagnosed with
allergic asthma
Patients diagnosed with
allergies such as hay
fever
Patients diagnosed ...


COPD is characterized by airflow limitation caused by
chronic bronchitis or emphysema often associated with
long term t...


Chronic Bronchitis is characterized by
Chronic inflammation and excess mucus production
 Presence of chronic productiv...
Normal versus Diseased Bronchi




Smoking
Air pollution
genetic (hereditary) risk


Night time waking with breathlessness or
wheeze is common in asthma and uncommon in
COPD.



COPD is rare before the a...
Classification of COPD Severity
by Spirometry
Stage I: Mild

FEV1/FVC < 0.70
FEV1 > 80% predicted

Stage II: Moderate

FEV...
Physical examination
Signs of heavy smokers

Observe for clubbing

Distended neck vein on expiration

The presence of b...









Symptoms
Physical examination
Sample of sputum
Chest x-ray
High-resolution CT (HRCT scan)
Pulmonary funct...


Give antibiotics to treat infection



Give bronchodilators to relieve bronchospasm, reduce
airway obstruction, mucosa...


Stop smoking



Oxygenation with low concentration during the acute episodes



In asthma adrenaline ( epinephrine) S...
Oxygen therapy




Used as long-term continuous therapy, during exercise,
or to relieve acute dyspnea
Improves survival ...


Annual flu vaccine




Reduces risk of flu and its complications

Pneumonia vaccine


Reduces risk of common cause o...
G lobal Initiative for Chronic
bstructive
O ung
L isease

D

November 19, 2006
World COPD Day, Kyoto Japan
Revised 2006

Definition, Classification
Burden of COPD
Risk factors
Pathogenesis, pathology,
pathophysiology
Management
P...
THANK YOU
Management  of  asthma and copd
Management  of  asthma and copd
Management  of  asthma and copd
Management  of  asthma and copd
Management  of  asthma and copd
Management  of  asthma and copd
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Management of asthma and copd

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  • Environmental and genetic factors lead to atopic sensitization, which may be asymptomatic. Together with local tissue factors it can develop to clinical disease. The balance between these factors is responsible for the allergic phenotype
  • Atopy involves the capacity to produce IgE in response to common environmental proteins such as house dustmite, grass pollen, and food allergens. From the Greek atopos meaning out of place.
    A hereditary disorder marked by the tendency to develop immediate allergic reactions to substances such as pollen, food, dander, and insect venoms and manifested by hay fever, asthma, or similar allergic conditions. Also called atopic allergy.
    Atopy involves the capacity to produce IgE in response to common environmental proteins such as house dustmite, grass pollen, and food allergens. From the Greek atopos meaning out of place.
  • This combination is available today in both metered dose and dry powder inhalers (Rotacaps).
    It is available in 3 different Rotacap strengths where the dose of formoterol remains constant but the budesonide dose varies according to the need (severity of asthma); i.e. 100, 200 and 400 mcg of budesonide in 3 different Rotacaps.
  • One theory that might explain why we seem to be more vulnerable than ever to allergic disease is called the hygiene hypothesis. We’re all born with an abundance of TH2 immune cells designed to fight internal parasites. Exposure to infections triggers the development of TH1 immune cells, designed to fight bacteria and viruses, shown here on the left.
    Press space bar
    With no exposure to infections, the TH1 immune cells never take over, illustrated by the right arrow. Investigators theorize that with few parasites to conquer in the modernized West, TH2 immune cells might have turned on harmless allergens instead, resulting in more allergic disease. This hypothesis is based on studies showing lower asthma rates for children who live on farms, attend day care centers, have indoor pets or older siblings; all things that expose children to higher levels of bacteria and infection. Children who have delayed development of TH1 cells, possibly because they aren’t exposed to infections through contact with animals, dirt and other children, seem to have more allergies and might be more predisposed to asthma.
    Press space bar
    SOURCE: Busse WW, Lemanske RF. Advances in Immunology. NEJM. 2001 Feb; 344(5):350-362.
  • So who can be helped by this treatment?
    Patients diagnosed with allergic asthma.
    Patients with allergies such as hay fever.
    Patients diagnosed with sinusitis that predisposes them to asthma.
    Patients diagnosed with an allergy to insect stings.
    Press space bar
  • When used for more than 15 hours per day in patients with severe COPD (pO2 &lt; 60 mm Hg), oxygen has been shown to increase survival. It doesn’t improve survival in patients with only moderate COPD or nocturnal desaturation only. Benefits on quality of life are unclear, but oxygen may improve general alertness and psychological state in some patients. Oxygen therapy can be used as long-term with continuous delivery, only during exercise, or to relieve acute dyspnea.
    GOLD, 2009; Rabe, 2007; Cranston, 2008
  • Management of asthma and copd

    1. 1.      A chronic inflammatory disorder of the airway Infiltration of mast cells, eosinophils and lymphocytes Airway hyperresponsiveness Recurrent episodes of wheezing, coughing and shortness of breath Widespread, variable and often reversible airflow limitation
    2. 2. Predisposing Factors  Atopy Causal Factors  Indoor Allergens      Outdoor Allergens    Domestic mites Animal Allergens Cockroach Allergens Fungi Pollens Fungi Occupational Sensitizers Contributing Factors Respiratory infections Small size at birth  Diet  Air pollution   – Outdoor pollutants – Indoor pollutants  Smoking – Passive Smoking – Active Smoking
    3. 3. Environmental factors Mucosal inflammation Atopic sensitization Phenotype Genetic factors Structural changes
    4. 4. 1. Extrinsic or allergic:       1. History of `atopy` in childhood Family history of allergies Positive skin test Raised IgE level Below 30 years of age Less prone to status asthmaticus Intrinsic or Idiosyncratic:      No family history of allergy Negative skin test No rise in IgE level Middle age onset Prone to status asthmaticus
    5. 5. CLASSIFY SEVERITY STEP 4 Severe Persistent STEP 3 Moderate Persistent STEP 2 Mild Persistent STEP 1 Intermittent Clinical Features Before Treatment Nighttime PEF Symptoms Symptoms Continuous <60% predicted Limited physical Frequent Variability >30% activity Daily Use β2-agonist daily Attacks affect activity a week >1 time but <1 time a day < 1 time a week Asymptomatic and normal PEF between attacks >1 time week >2 times a month <2 times a month >60%-<80% predicted Variability >30% >80% predicted Variability 2030% >80% predicted Variability <20% The presence of one of the features of severity is sufficient to place a patient in that category. Global Initiative for Asthma (GINA) WHO/NHLBI, 2002
    6. 6.  GINA Guideline clearly states that THERE IS NO CURE FOR ASTHMA, But appropriate management most often leading to CONTROL of asthma
    7. 7.     Relievers Preventers Peak Flow meter Patient education
    8. 8. - Rescue medications Quick relief of symptoms Used during acute attacks Action lasts 4-6 hrs
    9. 9.     Short acting β 2 agonists Salbutamol Levosalbutamol Anti-cholinergics Ipratropium bromide Xanthines Theophylline Adrenaline injections
    10. 10. Selective β2 agonist ATP cAMP Relaxation Theophyline 5’-AMP Ipratopium Ach Vagus nerve
    11. 11. - Prevent future attacks Long term control of asthma Prevent airway remodelling
    12. 12. Corticosteroids Prednisolone, Betamethasone Beclomethasone, Budesonide Fluticasone Long acting β2 agonists Bambuterol, Salmeterol Formoterol Anti-leukotrienes Montelukast, Zafirlukast Xanthines Theophylline SR Mast cell stabilisers Sodium cromoglycate COMBINATIONS Salmeterol/Fluticasone Formoterol/Budesonide Salbutamol/Beclomethasone
    13. 13. SALBUTAMOL INHALER 100 mcg: 1 or 2 puffs as necessary LEVOSALBUTAMOL INHALER 50 mcg : 1 or 2 puffs as necessary
    14. 14.  Formoterol ( fast relief and sustained relief ) +  Budesonide ( twice or even once daily use ) Dose: 1- 4 puffs ( OD/BD ) Another combination Salmeterol + Fluticasone
    15. 15.  Metered dose inhalers  Dry powder inhalers (Rotahaler)  Spacers / Holding chambers
    16. 16. Dry Powder Inhaler Metered Dose inhaler Spacer
    17. 17.     Step I: When symptoms are less than once daily occasional inhalation of a short acting Beta-2 agonist – salbutmol, terbutaline. If used more than once daily – step II (Mild episodic asthma) Step II: Regular inhalation of low-dose steroids. Alternatively, cromoglycates. Beta-2 agonist as and whenever required (Mild chronic asthma) Step III: Inhalation of high dose of steroids (800 mcg) + Beta-2 agonist. Sustained release theophylline may be added. LT inhibitors may be tried instead of steroids (Moderate asthma with frequent exacerbations) spacers Step IV: Higher dose of steroid (800 to 200 mcg) + regular beta-2 agonist (long acting salmeterol) Additional treatment with oral drugs – LT antagonist or SR theophylline or oral beat-2 agonist
    18. 18. allergen allergen avoidance avoidance indicated indicated when possible when possible pharmacotherapy pharmacotherapy safety safety effectiveness effectiveness easy to be administered easy to be administered AR AR patient's patient's education education immunotherapy immunotherapy always indicated always indicated effectiveness effectiveness specialist prescription specialist prescription may alter the natural may alter the natural course of the disease course of the disease
    19. 19. Birth:TH2 Older siblings: Many infections [TH1 stimuli] Allergen Exposure TH1 No allergies Source: Busse WW, Lemanske RF. N Engl J Med 2001. Only child: Few infections Still TH2 Allergies
    20. 20.     Patients diagnosed with allergic asthma Patients diagnosed with allergies such as hay fever Patients diagnosed with sinusitis that predisposes them to asthma Patients diagnosed with insect sting allergy
    21. 21.  COPD is characterized by airflow limitation caused by chronic bronchitis or emphysema often associated with long term tobacco smoking  This is usually a slowly progressive and largely irreversible process  Consists of increased resistance to airflow, loss of elastic recoil, decreased expiratory flow rate, and overinflation of the lung.  COPD is clinically defined by a low FEV1 value that fails to respond acutely to bronchodilators, a characteristic that differentiates it from asthma.
    22. 22.  Chronic Bronchitis is characterized by Chronic inflammation and excess mucus production  Presence of chronic productive cough   Emphysema is characterized by Damage to the small, sac-like units of the lung that deliver oxygen into the lung and remove the carbon dioxide  Chronic cough  *Source: Braman, S. Update on the ATS Guidelines for COPD. Medscape Pulmonary Medicine. 2005;9(1):1.
    23. 23. Normal versus Diseased Bronchi
    24. 24.    Smoking Air pollution genetic (hereditary) risk
    25. 25.  Night time waking with breathlessness or wheeze is common in asthma and uncommon in COPD.  COPD is rare before the age of 35 whilst asthma is common in under-35.
    26. 26. Classification of COPD Severity by Spirometry 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 < 0.70 FEV1 < 30% predicted or FEV1 < 50% predicted plus
    27. 27. Physical examination Signs of heavy smokers  Observe for clubbing  Distended neck vein on expiration  The presence of barrel chest  Observe for abdominal breathing  The use of pursed lips breathing and chest movement  Auscultate the chest& listen for musical wheezes characteristics of chronic bronchitis 
    28. 28.         Symptoms Physical examination Sample of sputum Chest x-ray High-resolution CT (HRCT scan) Pulmonary function test (spirometery) Arterial blood gases test Pulse oximeter
    29. 29.  Give antibiotics to treat infection  Give bronchodilators to relieve bronchospasm, reduce airway obstruction, mucosal edema and liquefy secretions.  Chest physiotherapy and postural drainage to improve pulmonary ventilation.  Proper hydration helps to cough up secretions or tracheal suctioning when the patient is unable to cough.  Steroid therapy if the patient fails to respond to more conservative treatment.
    30. 30.  Stop smoking  Oxygenation with low concentration during the acute episodes  In asthma adrenaline ( epinephrine) SC if the bronchospasm not relieved.  Aminophylins IV if the above treatment does not help.  IV corticosteroids for patients with chronic asthma or frequent attack.  Sedative or tranquilizers to calm the patient.  Increase fluids intake to correct loss of diaphoresis and inaccessible loss of hyperventilation.  Intubations and mechanical ventilation if there is respiratory failure .
    31. 31. Oxygen therapy   Used as long-term continuous therapy, during exercise, or to relieve acute dyspnea Improves survival in COPD patients with severe hypoxemia (partial pressure of oxygen [pO2] < 55 mm Hg or oxygen saturation [sO2] <88%) (Strength of Recommendation [SOR]: A)   When used for >15 hours daily Does not improve survival in patients with moderate Cranston, 2008 hypoxemia or desaturation at night GOLD, 2009
    32. 32.  Annual flu vaccine   Reduces risk of flu and its complications Pneumonia vaccine  Reduces risk of common cause of pneumonia
    33. 33. G lobal Initiative for Chronic bstructive O ung L isease D November 19, 2006 World COPD Day, Kyoto Japan
    34. 34. Revised 2006 Definition, Classification Burden of COPD Risk factors Pathogenesis, pathology, pathophysiology Management Practical Considerations
    35. 35. THANK YOU

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