NEW APPROACH IN MANAGEMENT OF BRONCHIAL ASTHMA

NEW APPROACH IN MANAGEMENT OF BRONCHIAL ASTHMA

Sunil V Shah
Chest Physician, Mumbai; Rotary Asthma Education Centre (Patients and Doctors) C/o - Rotary Service Centre, Near IBP Petrol Pump Babulin, SV Road, Malad (W), Mumbai - 64.

The prevalence of asthma is increasing. A cure is not yet available but control of the condition is possible in majority of the patients. However, many are suffering unnecessarily because of delayed diagnosis, high expectations and poor selection of treatment and inhaler devices. Some who are given the correct treatment do not take it and this often reflects inadequate information and poor communication between doctor and patients.

Asthma suffering can be reduced on the following guidelines : good management, better education, improved communication, regular supervision and personalisation of advice to the individuals enabling them to control their own disease.

INTRODUCTION

Asthma is the only treatable chronic condition that is increasing in frequency and severity. The reasons for the rising prevalence of the condition are unclear. The tendency to the atopic is inherited via a single gene (Cookson and Hopkin 1989), but not all with the tendency develop the disease. The genetic factors are unlikely to have altered over a short time period and so we must look for recent change in the environment. The levels of a number of invisible pollutants such as oxides of nitrogen and ozone have increased. Smoking, automobile and industrial pollutions have increased to a great extent.

More than half of all asthma starts in childhood and at least a third before the age of 3 years. Prevalence rates vary according to diagnostic criteria but are unlikely to be less than 10% of the childhood population. Sadly, the morbidity data are accompanied by an increase in mortality every year. This picture of increasing suffering and death rate is occurring at a time of increased use of antiasthma drugs.
TEN POINT PLAN FOR THE LONG TERM MANAGEMENT OF ASTHMA
1. Diagnosis : Lung Functions

The first step in the plan is to measure the patient’s lung function before and after bronchodilator using spirometry to diagnose asthma. Underdiagnosis leads to morbidity and suffering despite the wider availability of treatment. In children, a greater awareness that any respiratory symptom could be due to asthma is needed. Wheezing is common but coughing (esp. at night and on exercise), chest tightness and exertional breathlessness are also likely symptoms. A clear chest in absence of rhonchi doesn’t rule out asthma. If spirometry is not available, peak expiratory flow rate (PEFR) can be measured. Reversibility can be confirmed by immediate response to nebulized B2 by MDI through a spacer or long term bronchodilators or oral steroids for a short period.

This will not however measure the severity of the disease.

2. To assess severity

The second step is to assess severity by history, measuring bronchial hyper reactivity (BHR) or diurnal variation in airflow rates.

A. History - a symptom free period between two attacks and medicine requirement on day to day basis will give fairly good idea. To confirm symptom free period ask :

Breathlessness on exertion,

Nocturnal or early morning cough, tightness in chest,

Easy fatiguability between two attacks.

Nature of medication, especially oral steroids (which are available very easily across the counter or sold by quacks as asthma medicines e.g. asthma sanjivani, Bangalore) will help in judging and planning treatment.

B. BHR (Bronchial Hyper Reactivity) : In asthmatics, the bronchi (airway) are twitchy / sensitive. Depending upon BHR, severity of asthma varies. This can be measured by giving graded doses of histamine and monitoring fall in lung functions. Histamine concentration required to reduce FEV1 by 20% is called PC 20. Low PC 20 will indicate severe asthma. However, the tests to measure BHR are complicated and not easily available in practice. Fortunately, there is a close correlation between PC 20 and airflow variability. Peak flow meters are readily available, to measure PEFR.

C. Diurnal variation in PEFR : Patients are instructed to take and recorded PEFR (before and after bronchodilator) in morning and evening for 2 weeks. Out of these values the highest measurement minus the lowest and divided by the highest gives the per cent air flow variability. A value of 30% or greater indicates severe asthma, 20-30% moderate and 10-20% mild asthma. This correlates well with BHR measured by histamine.

3. Explain and assess socio economically

This third part of the plan is to tell the patient about the disease, about the method of assessing severity, monitoring and the plan of treatment. Stress on the misconceptions about the disease in society, the usefulness and safety of inhaled medicines, the possibility of receiving steroids in medicines which are unlabelled and given by quacks.

Assess patient’s social background in terms of acceptance of inhaled medication. Judge patient’s earning capacity and liabilities to ascertain whether he will afford inhaled medicines.

4. Plan treatment

The aims are 1) Symptom free period, 2) Maintain maximum PEFR, 3) Minimum medication a. Number, b. Doses, 4) Continuing preventive medication on long term to reduce BHR, 5) Minimise oral steroids, 6) Cost effectiveness : As compared to developed countries where inhaled B2 + inhaled steroids form the mainstem in therapy, we still depend a lot on oral medication because they are easily acceptable and relatively less costly.

Drug history - regarding intolerance to oral B2 (tremors, cramps, weakness) to xanthines (gastritis, reflux oesophagitis) should be asked for before planning.

Selection of inhaler device both relieving (B2 agonist) and preventive (DSCG, BDP, BUD) are best taken by inhaled route. This permits small quantities of drug to be delivered directly to the site of action resulting in early action and minimising side effects to a great extent. Whilst the metered dose inhaler is the most commonly available device, many patients can’t coordinate activation with inspiration. For these and other problems of manual dexterity a dry powder inhaler or a spacer or a chamber device is more appropriate. Correct selection of the device and instruction on its use are almost as important as selection of the correct treatment. However, it is observed that least attention is paid to this subject. What is needed is careful preliminary selection of the best device for that individual patient followed by careful instructions, follow up and rechecking ofTreatment should be considered in a stepwise manner as described below, at the step most appropriate for the initial severity of the patient’s condition and medication being continued in past, on day to day basis.

A short course of oral steroids may be needed at any time to control asthma.

Step 1 - Patients who have infrequent symptoms, without sleep disturbance, need B2 agonist preferably by MDI salbutamol 100-200 mg or terbutaline 250-500 mcg 3-4 times a day as required. The alternative is dry powder inhalation by rotahaler. In those who find this difficult, oral form of salbutamol 2-4 mg theophyllin 100-200 mg can be started.

Step 2 - Patients who need to take bronchodilators (B2 + Theophyllin) almost daily, with nocturnal symptoms and persistently low PEFR or abnormal lung functions require regular inhaled anti inflammatory drugs. 1. Sodium cromoglycate (5-20 mg) 4 times a day (disadvantage - mild, costly, poor compliance as dose frequently is very high), 2. Inhaled steroids beclomethasone diproprionate (BDP) or Budesonide (BUD) 100-400 mcg twice daily.

Step 2 - (Alternative) Considering the cost and difficulty in acceptance of inhaled medication, non availability of trained persons to instruct and follow inhalation technique, a trial of theophyllin is worth a while when it has been shown to have anti inflammatory effects. Theophyllin (Anhydrous and preferably long acting) in the dose of 10 mg/kg/day, if tolerated, increase the dose, in increments of approximately 25% at 3 day interval to 16-18 mg/kg/day. Make sure that patient has no gastritis or reflux oesophagitis.

Step 3 - Persistent symptoms esp. at night with low peak expiratory flow rates. Add theophyllin with anti inflammatory drugs if it has not been started. A long acting B2 agonist (salmeterol) should be added. Oral long acting salbutamol (4-8 mg) or terbutaline (5-7.5 mg) can be used as an alternative.

Step 4 - Maintenance treatment with oral corticosteroids. This is given if adequate control is not achieved in step 3. Preparation with short half life e.g. prednisolone is preferred, esp. in alternate day regimen to minimise suppression of adrenal pituitary hypothalamic axis.

Step 5 - High dose of inhaled bronchodilators with nebuliser with special solution of salbutamol (5 mg) terbutaline (10 mg) 3-4 times/day. The use of nebuliser without proper evaluation is not advisable. Before considering giving nebuliser bronchodilator, increased bronchodilator, increased bronchodilation without unacceptable side effect should be demonstrated.

Step 6 - High dose of inhaled bronchodilators with nebuliser, steroids BDP or BUD should be increased to a maximum daily dose of 2 mg. A large volume spacer device is recommended to reduce oropharyngeal candidiasis and systemic absorption. Internationally this is advocated at step 3 but because of high cost of therapy it is not practical in India.

Step 5 and 6 should be considered depending upon patient’s economic background.

Step 7 - Treatment with short course of oral steroids : 1. Symptoms and PEFR gets progressively worse each day, 2. Sleep is disturbed by asthma, 3. Morning symptoms persist until midday, 4. Emergency nebuliser or injectable bronchodilators are needed. Give prednisolone 2 to 40 mg daily until two days after full recovery, when the drug may be stopped or the dose tapered.

Step down - The patient’s requirement for treatment should be reviewed from time to time. If asthma is well controlled, (asymptomatic, optimum PEFR) a step wise reduction in the medication must be planned. In chronic asthma a 6 month period of stability should be shown before stopping anti inflammatory drugs.

OTHER TREATMENT

Anti histaminics including ketotifen have proved disappointing in clinical practice. There is anecdotal evidence that some patients have benefitted from the use of acupuncture, ayurvedic and homoeopathic treatment but so far there are no controlled clinical trials to justify the same. Hyponsensitization / desensitization is also not accepted because of uncertainty about the result, cost and availability of better treatment.

5. Give sufficient doses to maintain best lung function

This is possible with regular monitoring of PEFR at home. If normal PEFR can’t be achieved, the best PEFR readings can be maintained.

6. Investigate trigger factor

This requires taking a careful history and performing skin test (pollens, fungi, animal dander, mite, dust, etc.) and in some cases provocational tests with occupational ingested agents. Where it is practical, these trigger factors should be removed.

7. Treat aggravating conditions

Asthma is worsened by smoking, rhinitis, gastric reflux, and excessive snoring. Smoking should cease. The other conditions should be investigated and treated.

8. Write a crisis plan

A patient has to be briefed about the symptoms of exacerbation and medicines to be taken in emergency. They should be taught diaphragmatic breathing to minimise sense of breathlessness.

9. See the patient regularly

Regular visits are needed to monitor progress, reassure the patient, check inhaler technique, and adjust doses of bronchodilators. This will prevent exacerbation and hospitalization.

10. Minimise therapy

See step down , no. 4.

PROBLEM AND SOLUTION

Making the correct diagnosis and prescribing the correct treatment will only reduce asthma suffering if the treatment is taken by the patient. To what extent do patients with asthma comply with medical advice?

A. Diagnosis / misunderstandings - Asthma is feared so much that doctors don’t use the word as patients especially with mild disease don’t accept it and seek alternative therapies giving up reliever and preventive treatment. Patients education is the only solution.

B. Lack of confidence in efficacy. The belief that allopathic medication will only give temporary relief and there is no cure, prevents many patients from regularly taking medication except for in emergencies or when symptoms become unbearable.

C. Fear of side effects / dislike of drugs : Allo pathic medicines have lot of side effects; antibiotics are frequently given by family physicians in acute attacks : Chronic use of oral steroids by many have made a lot of people aware about their side effects. This prevents patients from taking long term medication.

D. Difficulties with method of administration : inhaled medications are not accepted by many thinking that they are harmful, habit forming and used only in emergency and very severe disease. This is true with many doctors, majority of them are very much against steroid inhalers.

Extensive education of doctors, patients and lay people will be the only solution to the above problems. Efforts to decrease cost of medication especially inhalers and spacers will also help.

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