2. Prevalence of Asthma
• Estimated prevalence of Asthma is increasing 50% every 10 years
• India contributes to 11.1% of the global asthma burden
• India accounts for over 42% of all the global asthma deaths
Respirology 2018; Lung India. 2015 Apr; 32(Suppl 1): S1–S2; Global report on Asthma 2018
358 million 37.8 million
3. 3
Thirteen of the top 20 most polluted cities in the world are in India,
with Delhi, the capital of India, topping the list.
India also tops the list of air pollution-related deaths with 2.51
million (M) deaths every year.
India ranks 1st in its contribution to global mortality due to asthma
4. Prevalence Of Symptoms on a singlE Indian healthcare Day
On a Nationwide scale (POSEIDON) study
• to investigate the point prevalence of symptoms
and medical conditions for which a patient visits a
primary health-care practitioner in India
• to study the distribution of disease patterns
across different regions in India, age-related and
gender-related disease profile patterns, and
comorbid conditions associated with common
diseases.
5. POSEIDON STUDY
• First large nation-wide study in India
• Study involved :-
2,04,912patients
12,000general practitioners,
general physicians, and
paediatricians
880 cities and towns
Feb 1, 2011, the day of the POSEIDON Study
Lancet Glob Health 2015; 3: e776–84
6. 0%
10%
20%
30%
40%
50%
60%
50.6%
25.0%
12.5%
9.0%
6.6% 6.3% 6.0%
4.2% 3.8% 3.6%
2.1% 1.6% 1.6% 0.8% 0.7%
Prevalence
(%)
Organwisesymptoms
Reasons for a Doctor Visit in India
N= 204,912
880 cities/towns
Age: 2 months to 107 years.
Lancet Glob Health 2015; 3: e776–84
Respiratory symptoms were the leading cause of visit to a health-care
provider across India. (50.6% of adult and 65% of all child patients)
7. • OADs (14.51%) such as asthma and COPD were the
second most common diagnosis after hypertension
(14.52%)
POSEIDON STUDY –
MOST COMMON
DIAGNOSIS
Lancet Glob Health 2015; 3: e776–84
8. Lets look at the Indian data on
asthma control among asthmatics
9. Asia-Pacific AIM Survey - to understand current asthma
management, level of asthma control, and its impact on
quality of life
Respirology 2013; 18(6): 957-67
Australia
India
China Hong Kong
Malaysia Singapore South Korea
Taiwan
Thailand
10.
11. highest frequency of exacerbations
lowest level of controlled asthmatics
highest levels of overnight hospitalizations
largest proportion patients who missed work or school
due to their asthma
Asthma in India was
associated with :
Respirology 2013; 18(6): 957-67
13. 13
Definition of Asthma
• Chronic inflammatory disorder of the airways
• Mast cells, eosinophils, T lymphocytes,
macrophages, neutrophils, epithelial cells
• Causes variable and recurrent episodes of
wheezing, breathlessness, chest tightness,
cough – especially at night or early
morning
• Associated with widespread, but variable
airflow obstruction that is often reversible
NHLBIAsthma Guidelines, EPR-3,Aug 2007
14. Disease Overview
The inflammatory response
not only leads to flow
limitation and smooth
muscle contraction but
also airway remodeling (if
not controlled).
Asthma is a complex
heterogeneous disorder
characterized by reversible
airflow limitation and
airway inflammation.
Airway remodeling
contributes to irreversible
airflow limitation and
functional limitation.
01
02
03
17. • Induced by airway inflammation
• Bronchoconstriction- Bronchial smooth muscle contraction
that quickly narrows the airways in response to exposure to
a variety of stimuli
• Airway hyperresponsiveness- an exaggerated
bronchoconstrictor response to stimuli
• Airway edema- as the disease becomes more persistent and
inflammation become more progressive, edema, mucus
hyper secretion, and formation of inspissated mucus plugs
further limit airflow.
Airflow Limitation
18.
19. • Reversibility of airflow limitation may be incomplete in
some patients.
• Persistent changes in airway structure
• Sub-basement fibrosis
• Mucus hypersecretion
• Injury to epithelial cells
• Smooth muscle hypertrophy
• Angiogenesis
Remodeling
20. Histopathology of asthma
•Tight structure with a predominance of
ciliated epithelial cells.
• Only few goblet cells in the epithelium.
•The lamina propia, is practically cell-
free.
• Inflammatory cells are not seen.
Same in both pictures (x 300)
Laitinen et.al. Allergy Proc 15,6:323, 1994
• Less ciliated cells
• Goblet cells hyperplasia
•Epithelium and lamina propia are
highly infiltrated (mainly eosinophils and
lymphocytes)
• Edema
• Basement membrane thickening
• Collagen deposition in the sub mucosa
Normal Asthma
23. ALLERGY One of the major reasons for airway inflammation in asthma
23
Allergen is the substance which induces an allergic response.
A reaction to a specific substance which is foreign to the body.
1. Trigger are factors that when
inhaled can start asthma.
2. They can vary from person to
person.
24. 24
1st Exposure - Sensitization Phase 2nd Exposure
Early Allergic
Response EAR
(5-30 mins after
exposure)
Chemotactic
Factors
Eosinophil
Basophil
Neutrophil
Late Allergic Response/LAR
(3-11 hrs after exposure)
Enters in
human body
Body produces IgE antibody
Antigen binds
Antibody
Antigen-Antibody
Complex
Excess antibodies
come and bind to
MAST CELL
Allergen Allergen
SENSITIZED MAST CELL
ALLERGEN binds to
SENSITIZED MAST CELL
Histamine
Leukotriene
Prostaglandin
ECP
MBP
Damage to Epithelial cells,
Increase in Mucus Production,
Inflammation
MAST
CELL
MAST
CELL
26. Cough is often dry and can have
harsh bursts
a whistling sound mainly when
you breathe out through
narrowed airways
Episodic
coughing
Wheezing
Shortness of breath which may
occur with activity or even at rest
Chest tightness Breathlessness
Hallmark features of asthma: symptoms occur mostly
at night (sometimes also called as nocturnal asthma)
and/ or after exercise/activity (sometimes also called as
exercise-induced asthma or EIA).
Symptoms
Common Asthma Triggers https://www.cdc.gov/asthma/triggers.html (Accessed on: 25 May 2022)
“
28. CRITERIA for Diagnosing Asthma
1. History taking of variable respiratory symptoms
2. Physical examination
3. Measurements of lung function
• Bronchodilator Reversibility test
28
29. History taking
(Ask questions to Diagnose Asthma)
29
More than one symptom (Wheeze, Dynpnea, Cough and
Chest Tightness) ?
Symptoms are often worse at night or on waking
Symptoms are often triggered by exercise, laughter, allergens, cold air
Symptoms often appear or worsen with viral infections
Symptoms occur variably over time and vary in intensity
Family history of allaergies or asthma
30. Calibrated with EU scale
Demo_4
Measurements of lung function
Spirometry OR
The Peak Flow Meter
30
31. 31
The Peak Flow Meter:
Helps diagnosing Asthma!
Peak flow meter in
asthma practice
Clinic
Home
monitoring
Occupational
asthma
Having a peak flow meter in
asthma clinic can help in:
1. Diagnosing asthma
2. Measuring effectiveness
of medications
A peak flow meter at home can
help the patients to:
1. Monitor asthma control
2. Improve adherence to
medication
3. Identify an impending
asthma attack
32. 32
1. Measure peak flow reading – 3 times – Take best of 3 Readings
2. Give bronchodilator
4. Measure peak flow reading again (PEFR) –Take best of 3 readings
3. Wait for 10 to 15 minutes
5. If: ≥20 % increase in this reading from Pre-Bronchodilator Value
6. Indication of a significant degree of reversible airflow obstruction
ASTHMA
Bronchodilator Reversibility test
34. Spirometry
• Performed by well-trained operators with well maintained
equipment
34
Endpoints
Adults: Increase in FEV1 of >12% and >200 mL from
pre-bronchodilator value.
36. Type of Drugs used in Asthma
36
Eg - SABA Eg – ICS or ICS/LABA
Bronchospasm needs a Reliever Inflammation (Swelling) needs a Controller
Duration of action: short Duration of action: long
Onset of action: faster Onset of action: slower
Quickly relieve symptoms Prevent asthma attacks
Rescue medicine, SOS Regular medicine
Bronchodilators Anti-inflammatory
Bronchodilation Anti-inflammatory
37. 37
What will happen if an asthmatic does
not take a controller everyday?
Explaining the importance of prescribing controllers to a
doctor prescribing only bronchodilators to patients
38. THE STORY OF ASTHMA TREATMENT
38
Traditional treatment
Occasional Relievers
Ideal treatment
Regular Controllers
Steroid
In Asthma
40. Which are the various guidelines on asthma management?
1. GINA (Global INitiative for Asthma)
2. BTS (British Thoracic Society)
3. NAEPP (National Asthma Education and Prevention
Program)
4. CTS (Canadian Thoracic Society)
5. ICS/NCCP (Indian Chest Society / National College of
Chest Physicians)
40
42. Goals of asthma management
1.Achieve and maintain control of symptoms
2.Maintain normal activity levels
3.Maintain pulmonary function close to normal levels
4.Prevent asthma exacerbations
5.Prevent asthma mortality
6.Avoid adverse effects from asthma medications
43. • Airway inflammation is found in most patients with asthma, even in those with
intermittent or infrequent symptoms.
• Patients with even mild asthma can have severe exacerbations
Addressing the concerns around SABA-only treatment:
• Although SABA provides quick relief of symptoms, SABA-only treatment is associated
with increased risk of exacerbations and lower lung function
• > 3 canisters of SABA/year – Increased risk of emergency visit or hospitalisation
• > 12 canisters of SABA/year – Increased risk of death
• Regular use of SABA is associated with increased allergic responses and airway
inflammation
44. GINA 2023 recommendations for treatment
of asthma in adults and adolescents
Anti-
inflammatory
reliever
As needed ICS-
SABA in track 2 is
currently
recommended only
in steps 3-5
47. Despite addition of ICS-SABA as reliever in track
2, track 1 remains the preferred treatment option
Simplicity of the approach for patients and clinicians
A single medication used for symptom relief, and for maintenance treatment if needed
Treatment stepped up or down by changing the number of doses
Inbuilt asthma action plan: rapid increase in dose of both ICS and formoterol
As-needed formoterol is more effective than SABA in reducing severe exacerbations
In Steps 3–5: weight of evidence for effectiveness and safety of MART versus
comparators (n~30,000)
One RCT (n=3132) with as-needed ICS-SABA (Papi et al, NEJMed 2022)
In Steps 1–2: weight of evidence (n~10,000) for effectiveness and safety of as-needed-
only ICS-formoterol compared with SABA, and compared with ICS
One 6-month RCT (n=455) with as-needed ICS-SABA (Papi et al, NEJMed 2007)
Availability of medications
54. GINA 2023 report on management of
severe asthma
Regardless of regulatory approvals, GINA recommends biologic therapy for asthma only if asthma is severe, and
only if treatment has been optimized
Head-to-head studies are needed
Non-asthma indications for biologic therapy are mentioned only if the condition is relevant to asthma management,
or if it is commonly associated with asthma
Severe asthma guide will be published shortly in full size
55. Environmental considerations and inhaler
choices
• Which medication(s) suits the patient?
• Which inhalers are available to the patient?
• Can the patient use the prescribed inhaler correctly
after training?
• Which inhaler has the lowest environmental impact?
• Is the patient satisfied?
