“He who really understands what is involved in the breathing of man, has already sensed the breath of God.
Definition
Is a chronic, intermittent, inflammatory disease of the airways characterized by episodes of wheezing, coughing, breathlessness and chest-tightness. It is usually reversible but can be severe and occasionally fatal.
Prognosis
Good in 95% of chronic asthmatics. There has been some increase in asthma morbidity and mortality in recent times. Younger patients with extrinsic asthma do best. Rigorous medical regimens can reduce hospital admissions. Prognosis is acute episode is prior in the presence of (a) active accessory muscles, (b) poor response to initial treatment, (c) disturbance of consciousness, (Done) disappearance of wheezing in a profoundly fatigued patient, (e) low Pao2, (f) rising Pco2, and (g) presence of complications like pneumothorax, atelectasis.
Treatment
Treatment of an acute attack:
ASTHALIN inhaler x 1-2 puffs x to be taken early at the onset of the attack by the patient.
Inj. Deryphilin 2cc IM/ IV (Theo + Etophylin) or Inj, BRICANYL cc IM (Terbutalin) or Inj. ALUPENT 2ml IM/ SC (Orciprenalin = 5D-4)
If patient is young Inj. Adrenalin 0.5 ml S.C Isoprenalin Autohaler 1-2 puffs
If attack is severe
Inj. Aminophylin 10ml with 10 ml of 25% glucose I.V. slowly over 4-5 mins.
If nor relieved with aminophylin,
Repeat Inj. Aminophylin after 10 mins. Inj. Efcorin 100mg IV (Hydrocorisone) Inj. Decadran 2-4 cc IV or Inj. Betnelam 2-4 cc IV Oxygen by nasal catheter.
Take to a hospital for further management.
Maintenance Treatment:
I. General Advise:
1. Deep breathing exercises, e.g Pranayam 25 timesdaily. 2. Stop smoking completely, If smoker. 3. Avoid all allergens. i. Avoid dust. A housewife may be greatly helped by vaccum cleaner to clean dust. Use mask while dusting. ii. Avoid carpets on floor, which harbour duyst. iii. Avoid pest- cats, dogs and close contact with them. iv. Avoid industrial fumes in factory workers. v. If only particular food precipitates an attack avoid it e.g. cold drinks, particular fruits, fish, chocolates. vi. If any emotional or family problem try to sort it out or use transquiliser or consult psychiatrist. vii. For repeated attacks, advise change of weather i.e a holiday in dry climate, will help more than the drugs. viii. Avoid mosquito coils and mats. Use mosquito net or Odomos. ix. Avoid passive smoking.
II. Drug Therapy – Oral Bronchodilators
Use any one or more of the Bronchodilators. Salbutamol eg. Tab. ASTHALIN 4mg tds or Syp. ASTHALIN tsp tds and S.O.S Terbutalin e.g Tab. BRICANYL 5 mg. tds. Orciprenalin eg. Tab. ALUPENT 10mg 1-2 tds. Theopylin e.g Tab. Deryphilin 1tds
Use minimum required dose to keep the patient asymptomatic. If patient is well controlled on one drug, do not change the drug without valid reason. Frequent change of drugs confuses the patient who has to take it life long.
III. Inhaler therapy
This is the preferred mode of treatment today, with minimal side effects. It is currently considered as first line of treatment.
ASTHALIN Inhaler x 1-2 puffs x 3-4 times/ day (Salbutamol) BRICANYL Inhaler x 1-2 puffs x 3-4 times/ day (Terbutalin) Salmeterol Inhaler x 2 puffs x 3-4 times/ day (Salmetorol) Ipravent Inhaler x 1 puffs x 3-4 times/ day (Ipratropium)
The patient has to learn synchronization of the puff with inspiration. If he finds it difficult, use of spacehaler should be advised.
IV. If Bronchodilators, oral or inhaled fail to control the attacks or if bronchodilators are needed or 3 or more times per week, use steroid inhaler and transquiliser.
1. Beclate -50 inhaler -1 to 3 puffs/ day (Beclomethasine) or Pulmocort inhaler 2 puffs/ day (Budesonide). 2. Oral steroids be reserved only for emergencies. 3. Tab. Alprozolam 0.25 mg 1-2/ day. 4. At this stage, combined inhalers are most convenient, e.g Seroflow or Aerocort inhaler 1 puff 2-3 times/day.
V. If attacks are frequent in spite of inhaled steroid + bronchodilator combination, use Mast cell stabilizer.
1. Final inhaler 1-2 puffs x 4 times/ day (Sodium chromoglycate) or Tab. KETASMA 1mg bd x 3 months. 2. If after 3 months, the attacks are found to be controlled, the drug should be continue for 6 months- 1year.
VI. During an exacerbation of Bronchial Asthma.
1. Tab. PELOX 400mg. bd x 5. 2. Tab. WYSOLONE 5mg tds x 5, Then 1 bd x 5. 3. Treat acute attack as mention above.
How to use inhaler
You must ask the patient to bring the inhaher/ rotahaler to you and you must teach him/ her the correct way to use it. Because if the deug release is not co-ordinated with inspiration, then the drug is wasted, and the breathlessness will not be relieved.
Instructions to patient using Inhaler:
Shake the inhaler before use. Hold it upright. Hold the mouth piece between the teeth and close the lips around it. Breathe out through the nose, and start inhaling slowly through the mouth, with the head tilted slightly backwards. Press the canister to release one dose, while continuing to breathe steadily and deeply. Now remove the inhaler and hold the breath, as long as you comfortably can. Then exhale. Rinse the mouth, to wash out the drug deposited in the mouth. If 2 puffs are advised second puff should be taken after a gap of atleast one minute. For children and for tachypnoeic patients, use spacehaler, which does not require correct co-ordination of inspiration with drug release.
Instructions to patient using Rothaler:
Take a rotocap. Insert its transparent end into the hole of rotohaler and press it firmly. Rotate the base of Rotohaler- thus cutting open the Rotocap. Breathe our fully. Hold the mouthpiece between your teeth and seal your lips around it. Tilt the head slightly backwards and take a deep breathe through the Rotahaler. Hold the breath as along as you can comfortably can, than breath out. Repeat till all powder is inhaled. Rinse and gargle to wash out the drug in the mouth. Open the Rotahaler. Discard the empty capsule. Rinse the instrument in running water and leave it dry.
Bronchial Asthma Is one of the psychosomatic illnesses. So transquility of mind is very important part of mind.
Acute exacerbations are usually due to a change in weather.
If a patient gets dramatic relief in dry climate, and attacks otherwise, suggest him to change his residence if possible to a city with dry climate.
Home monitoring of PFR-To report to doctor if PFR drops below 70% of baseline. Eliminating irritants. Hyposensitisation Ensuring adequate hydration Attention to general health measures
Advice to Patient
Proper use of MDI. Home monitoring of PFR and to report if it falls below 70% Avoid iced drinks, spicy foods, and cold immersion. Keep living and bed room as dust free as possible Avoid exercise in exercise induced asthma. Avoiding allergens like dust, smoke emotional upsets and special foods. Breathing exercises, especially yoga. Avoid aspirin, tartrazine and sulfites (preservatives) Drink plenty of fluids and avoid dehydration.
Follow Up
Prearranged plan for any exacerbations. It should be remembered that after an exacerbation the bronchial hyper-reactivity persists for 4-6 weeks.
Inadequate Response
In the mild and moderate cases, if the response is poor, ensure patient compliance, prior to adding more potent therapy. Other causes that could be missed are Gastroesophageal reflux, congestive cardiac failure, frequent exposure to allergens, irritants like chemicals, pulmonary eosinophilia, bronchiectasis, pulmonary emboli, use of beta blokers, aspirin, ACE inhibitors, NSAIDs, hyperventilation in panic attacks, inhaled pentamidine, and premenstrual asthma. Watch patient with acute attack in the clinic or Casualty-Clinically, as well as with FEV1 measurements if possible, and if the response appears inadequate, consider hospitalization. Always when in doubt decide on in-patient management, rather than policy of ‘wait and watch’
Prevention
Use of Cromolyn (disodium Cromoglycate) Decreases nonspecific bronchial hyperreactivity in both allergic and non-allergic asthma. Works best in young asthmatics with extrinsic asthma, but may be effective in older patients with chronic asthma. Takes 4-6 weeks to achieve benefit and is helpful in 60-90% of patients. Any reactive bronchospasm canbe prevented by using beta-adrenergic agents earlier. Given an hour before, cromolyn can prevent exercise induced attack. Inhaled steroids like Beclomethasone are used as preventive in the chronic asthmatic with excellent results, and are safe. Leukotrine receptor antagonists are an add-on preventive in chronic asthma. Avoidance of allergens-Hyposensitisation works well against pollen, cotton dust, house mite and single allergens.
