ASTHMA Being a chronic inflammatory airway disorder as well as one of the most common chronic diseases, asthma has

affected about 300 million people worldwide1, and 284,046 deaths per year2 and incidence increasing by 50% every decade3. Fortunately asthma can be effectively treated and most patients can achieve good control of their disease4. The scenario here, of poorly controlled asthma, has delineated the common picture in the primary care level of Bangladesh. This essay will try to discuss about the comprehensive reassessment of this patient having frequent respiratory symptoms and review of current history and treatment along with management through every steps of asthma care. Content: As the patient seeks medical attention the goal is to relief his initial symptoms followed by proceeding towards a stepwise approach to asthma care. So, firstly assessment through careful clinical history5 of -Specific symptoms such as cough (Cough is the main symptom in young children, worse at night and usually non-productive.), wheeze and chest tightness are common in young and middle age population, breathlessness is common in all asthma patients of any age group with/without coexistence of some respiratory and non respiratory causes of breathlessness and nasal symptoms (history of sneezing, rhinorrhoea, nasal-itching, nasal blockade or sinusitis). As there is strong relationship between allergic rhinitis & asthma, 75%

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to 80% patient with asthma is believed to have allergic rhinitis. If allergic rhinitis is controlled asthma is also controlled6.) .-Severity of symptoms: how do they affect normal activity, time of school/work -Frequency of symptoms: how often, daily, weekly or less frequent -Variability of symptoms: seasonal or diurnal variation. -When did symptoms start? -What makes symptoms worse: trigger factor? -What makes symptoms better: bronchodilator, etc. -Trigger factors: Upper respiratory tract infection, Dust, Pollen, Exercise, Active/passive smoking (Cigarette smoke including passive smoking is one of the most common asthma triggers7,8 & can lead to increase bronchodilator use in children9), any pets in home, Feather Pillows. Exposure to house dust mite, moulds, pollen, spores, and animal/insect dander can worsen patients asthma10. Any type of viral infection (particularly human Rhinovirus) can frequently precipitate & exacerbate symptoms11 -Psychological condition of the patient like stress, emotion, economical condition, unemployment, psychosis - Patients compliance & adherence to treatment: Inadequate patient adherence to prescribed treatment regimen is a major cause of poor clinical outcome in treating asthma12 -Reduction of exposure to occupational allergens13, change of occupation or workplace may impose a load of triggers that are responsible for the frequent Student No: 54262 Student Initials: DRMI Page 2

respiratory symptoms14. Work related factors can be responsible for up to 1/3rd of all asthma cases15. At present >400 workplace substances have been identified as asthmagenic/allergygenic16, visiting new place or change the time of working. -Personal history like smoking, exercise (about 50%-60% of patient experience exercise induced asthma even took asthma medication prior to or after exercise17), allergy (any food /drinks), level of literacy -Presence of co morbidities: COPD, RTI like Tuberculosis, Heart disease, GERD, Obesity etc. Co-morbid condition such as obesity, chronic kidney disease, hypertension etc. causes poor control of asthma18
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Medications like NSAIDS, beta blocker or using eye drop19.

Age plays an important role. Younger children, adolescent and very old patient have less asthma control. In case of young adult, most start smoking at early age20. Their peer pressure makes them switch-off the regular therapy21. History of childhood asthma History of familial association or atopy or level of environmental control Treatment history: Whether Correct dose/drug? Inhaler technique? History of sleep disturbance, acute attack, of hospital admission or visit emergency department of hospital, Is there any action plan Control over disease by assessing control (rule of 2)22 by practical tool: If asthma episodes are 2/week, or nocturnal attacks are 2/month or number of canister

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of reliever (salbutamol) inhaler used is 2/year, it means patients asthma is not controlled. Physical examination -It includes respiratory rate, pulse rate, anemia, cyanosis, shape of chest, chest indrawing, ear & eye (sign of allergy), nose & mouth (signs of rhinitis), lungs (wheeze or crackles) Objective tests for reassessment of severity and control: Laboratory investigations23: Spirometry (Gold Standard), PEF (Peak expiratory flow) preferably serial peakflow monitoring, Bronchodilator reversibility testing, Exercise testing Routine Investigations: CBC including Total Circulating Eosinophil count Sputum for AFB and C/S Chest and Sinus X-rays S. IgE level, Skin prick testing CT of Chest Video Bronchoscopy Laryngoscopy Other tests, if suggestive Questionnaires: The RCP 3 questions Student No: 54262 Student Initials: DRMI Page 4

The ACT (Asthma control test) The Asthma therapy assessment questionnaire (ATAQ) The Asthma control questionnaire (ACQ) The Asthma control scoring system (ACSC) In Bangladesh we use Dhaka criteria24 1. Do you have breathlessness everyday? Yes=1 No=0

2. Do you have nocturnal attack of breathlessness more than 2 times / months? Yes=1 No=0

3. Have you suffered from breathlessness which was severe enough to take steroid tablets or injections, nebulizer therapy, aminophylline injections or hospital admission? Yes=1 No=0

4. Do you have persistent breathlessness for last 6 months or more or are you taking steroid tablets for 1 year or more? Yes=3 No=0

5. Is patients baseline (during asymptomatic stage) PEF =60% of predicted value or less? Yes=1 No=0 Total score=7-0 For >5years to adult Score Recommended step 012Step 1 Step 2 Step 3 Page 5

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Step 4a Step 4b

5- 7 Step 5 or 6 Management strategy of the asthma patients depends on age of the patient, variety & severity of asthma. The aim of treatment is to reduce symptoms, preventing exacerbation and maintaining normal lung function. A treatment & management option of the patient includes pharmacological options, nonpharmacological options for gaining control and patient education with details self management plan including regular follow-up and review. If the patient is poorly controlled: If regular inhaled steroid (200-400mcg in children, 200-800mcg in adults beclometasone or equivalent) plus occasional bronchodilator fail to achieve the aims of treatment or if there is still symptoms then assessment of the following things Checking if the patient takes medication as prescribed, the inhaler technique of the patient, Reassessment of acute attack If moderate asthma PEF>50%(Best or predicted) Speech normal Respiratory rate <25 breath/minute Pulse rate <110 beats/minute Student No: 54262 Student Initials: DRMI Page 6

If acute severe asthma PEF 33-50%(Best or predicted) Cannot complete sentences. Respiratory rate 25 breath/min Pulse rate 110 beats per minute If life threatening asthma PEF<33% SpO2 <92% Silent chest Cyanosis, bradycardia Confusion or coma. Any warning signs of deteriorating asthma -Falling PEF or Wide variation of PEF -Inability to achieve optimum PEF after Beta 2 agonist -Increased symptoms -Sleep disturbance -Fall in exercise tolerance Student No: 54262 Student Initials: DRMI Page 7

-Increased need for or decreased effectiveness of bronchodilators. Pharmacological treatment options Step care management is the basic for any asthmatics and is like staircases. Treatment should be started at appropriate step in step care management. Then step up of stairs as long as asthma is uncontrolled and step down when patients asthma is fully controlled for 3 months. At any step with any treatment if the patient is in exacerbation Rescue Steroid Therapy should be advised in addition to ongoing therapy to get relief of symptoms. Indications of Rescue steroid therapy are Symptoms and PEFR get progressive worse day by day PEFR falls below 60% of patients personal best Nocturnal symptoms & sleep disturbance 2 a week Persistence of morning symptoms till midday Poor or no response to reliever medications (inhaled bronchodilators) Nebulized or injected bronchodilators are needed for control of symptoms on emergency basis. The dose of oral rescue steroid is 30-60 mg/day for adult and 1-2 mg/kg/day bodyweight in single morning dose or two divided dose for 3-14 days after meal. The patient has to be set in an appropriate step of the step care management system after the rescue steroid therapy. Reliever controller & preventer agents should be offered with proper demonstration of inhalation technique. Student No: 54262 Student Initials: DRMI Page 8

After managing exacerbation (if present) management should be with step care approach (TABLE 1) following Dhaka criteria. In every step must check inhaler technique and compliance and inform the patient the purpose of use of reliever and controller. Step up of stairs as long as symptoms uncontrolled and step down when symptoms are fully controlled for at least 3 months. Non pharmacological treatment options: Aims to identify factors which might modify the causes and reduce requirement for pharmacotherapy. Allergen avoidance: complete barrier bed coverings, carpet removals including soft toys from bed, over 55C washing of bed linen. Smoking cessation (nicotine replacement therapy, counselling), encouraging breast feeding that prevents early life wheezing, weight reduction in obese, taking influenza vaccine, taking bronchodilator before exercise. These options are equally important as pharmacological treatment. Because, modern health education need to encompass individual counseling, peer group discussion, behaviour modification, mass media and community organization as well as provision of health intonation recognition and avoidance of specific trigger will help the asthmatics. Asthma education: Patient education requires development of a good doctor-patient relationship by a considerate approach, simple language and avoiding medical terminology,

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Informing about basic concepts of asthma i.e. asthma is a chronic inflammatory disease where his airways are red and swollen; it may not be cured totally but may be controlled and the control may be lost due to some trigger factors. About concept of asthma medications (reliever, preventer), their doses, and side effects and how to cope with these side effects, explaining and demonstrating about using delivery device along with supplying illustrated leaflets. Asthma treatment is rarely short term (but not life long) and cant be discontinued as the symptoms resolve and whether feels good or bad, preventer therapy should be continued. He should be negotiated about self management plan including dose and duration of medications, controlling trigger factors, emergency measures and life style modification e.g. reduction of weight, if obese. He should be instructed about correct technique of peak flow and maintenance of peak flow chart and explained about relation between peak flow chart and modification of management plan. He must have knowledge about rescue action. If he has a mild attack of symptoms, he should inhale reliever drug and in emergency situation, he should start oral steroid before consulting doctor. He should recognize trigger factors and risk factors to take precaution, advice to stop smoking; avoid carpet, pet, insecticides etc. To prevent exercise induced asthma, he should use pre exercise medication, warm up exercise and optimize control. He should recognize and manage occupational asthma. The patient should know about prognosis of the disease. He should also know about the goal of treatment which is to maintain a near normal life by achieving complete remission of asthma. Student No: 54262 Student Initials: DRMI Page 10

The patient should be discussed about his conception regarding asthma and his misconceptions should be alleviated. There are some institutional approaches should be made like formation of asthma club with some asthma patients. They will meet periodically, share their experiences and exchanged their views in the presence of a physician who will educate, train and demonstrate them. The patient should inform the school authority and teacher about students asthma management plan. Guided self management plan: Here, the patient makes changes to their treatment in response to changes in the severity of their asthma, and in accordance with a predetermined plan. It has 3 basic steps: 1. The patient should construct a peak flow chart 2. Physician should identify best peak flow from patients peak flow chart. Physician should divide his peak flow chart into 3 zones (green, yellow, red) on the basis of best peak flow of the patient. 3. Then physician should give one prescription for each zone. PEF 100%--80% of personal best (green zone) - continue basic prescription PEF<80 %--> 50% of personal best (yellow zone) - increase dose of ICS, add LTRA and/or LABA PEF 50% or less (red zone) - add oral steroid Self management plan reduces asthma morbidity and need for acute medical services. It also reduces the risk of asthma death.

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The patient should be encouraged to keep asthma diary which contain PEF diary, required extra reliever medicine, information regarding possible triggers causing asthma exacerbation. Conclusion: Optimal asthma management requires25: Regular assessment and monitoring: The patient is advised for regular clinic visit every 2-4 week until good asthma control is achieved. 2-4 asthma checkups per year are advised for maintaining good asthma control. Lung function monitoring is advised annually (more often if inadequate control). The patient is advised for once daily PEF monitoring, preferably in morning when peak flows are typically low. Asthma is a totally controllable disease in majority of the cases by using regular medication avoiding triggers with individualized asthma action plan with proper asthma education and regular follow-up under a trained asthma physician.

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