Asthma – Dr. M. Sabir

(Asthma is a common respiratory problem characterized by symptom free periods (with ought treatment), but during this period basic pathological phenomenon e.g. inflammation of airways continues. If treatment is discontinued during this period attacks in future may be more frequent, more severe & may last for longer duration & may have difficulties in treatment.It is advisable,that patient should continue treatment even during symtem free periods as per advice of their treating physicans.)

Asthma is a serious health problem affecting more than 300 million people of all ages in countries throughout the world. This chronic disease affecting airways (the pipes that take air in & out to & from our lungs when we breathe) in the lungs, if not treated, can place severe limits on daily life, loss of productivity (man hour & school days in children) and reduced participation in family life. Although asthma rarely leads to death but if it remains uncontrolled it can be fatal, and is responsible for death of more than about 0.25 million people all around the world in a year. 1 to 18 % of the total population living in different parts of the world has been estimated to be suffering from asthma. This prevalence of asthma is increasing in most countries, especially among children. In India exact data are not available but it is estimated that approximately more than 250 lakh of adults are suffering from asthma. It can affect all age groups but is more common at younger age and affects both sexes. Before the age of 14, the prevalence of asthma is nearly two times more amongst boys than girls. As children get older the difference between two sexes narrows, and by adulthood the prevalence of asthma is greater in women than in men. Since last two decades there has been extensive research on newer treatment modalities which provide symptom free, productive & near normal life to asthma patients.

ASTHMA: CAUSATIVE AND PRECIPIPATING FACTORS

Healthy individual breaths about 8,000 – 10,000 liter of air per day at varying
temperature, humidity and atmospheric pressure through air passages (airways) in the lungs. During this process person is inhaling not only the vital oxygen gas but also many unwanted gases, particulate matters, organic & inorganic substances, organisms and pollens present in the atmosphere.

Exposure to any of these environmental factors & tobacco smoke (through both active and passive smoking) and frequent infections at an early age specially in those children whose parents or near relatives are suffering from asthma; create the state of hypersensitivity (atopy) and in many persons makes the airways overactive(hyper responsive) to develop asthma.

Exposure of these hyperactive airways of asthma patients to the any of the environmental factors (as mentioned) can directly irritate lining of airways or starts an allergic reaction (inflammation). This leads to swelling in the linings of the airways and production of sticky mucus secretions blocking the wind passages (airways) in the lung. These developments and spasm of airway muscles leads to narrowing of air tubes (airways). This makes it difficult for the air to go in and out of the lungs to cause difficulty in breathing (dyspneoa).

Variations in development of asthma in different persons exposed to same environment is related to the vast differences in the defense system(immune system) of individuals and quality & quantity of exposure (present & in past) to environmental factors.

Various factors responsible for the development & precipitation of asthma are infections (bacterial or viral), pollutants from automobiles & industries, extremes of changes in temperature (more so for cold), pollens, smoke from kitchen and burning of other fuels, debris from insects & pat animals’ skin & fur, exercise, cloudy weather (humidity), dust (house dust, thunder storms, dust from construction, grain, flour and wood ), strong smells, room fresheners, deodorants, sprays, fresh paint’s fumes from walls & furniture, insecticides, aspirin & many pain killers, some drugs used for high blood pressure(beta blockers), obesity, emotional instability, hormonal changes during menses & pregnancy, exercise etc.

SYMPTOMS OF ASTHMA

• Attacks of frequent cough & dyspnoea more so in night, affecting sleep
• Exertion causing cough and dyspnoea
• Whistling sound with breathing(wheezing)
• Chest tightness
• Attacks having Seasonal variation and /or related to exposure to particular environment etc.

Any of the above symptoms persisting for more than 5-7 days, related to particular season/circumstances indicates towards asthma. Fever generally does not occur.
Above symptoms can change in severity, may disappear with ought treatment and may also recur after a varying symptom free period.

DIAGNOSIS

Tuberculosis, pneumonia and other infective disease of lungs should be excluded with the help of X-ray, sputum, blood tests etc. Spriometry and peak flow meter helps in diagnosis of asthma and assessing the severity of disease. Tests for allergy (skin & blood) are sometimes helpful but are costly, difficult to perform and mostly unconclusive. Rarely to confirm the diagnosis tests for assessing airway resistance & hyperactivity (methacholin challenge test).

SOME FACTS RELATED TO ASTHMA

1. Many dignitaries and celebrities, world famous politicians, actors, sportsman are suffering from asthma are known to leads a successful life.
2. Its not contagious disease.
3. 25% of adults and 50% of children taking regular and proper treatment either become symptom free without drugs or minimal symptoms with very low doses of drugs.
4. Asthma in pregnant females if not treated properly, it adversely affects both mother and child health. Therapeutic doses of most drugs of asthma (taken by inhalation route) do not have harmful affect on mother and child during pregnancy and lactation.
5. First degree blood relatives of asthmatics have a greater chance of being affected by asthma, more so if both the parent are suffering from asthma.
Although asthma can not be completely cured but precautions and proper treatment can have full control on symptoms and a patient can lead a normal life.

ASTHMA: TREATMENT

Aims and Objectives of treatment:

• Symptom free normal activities
• Uninterrupted sleep.
• Less admission to hospitals
• Treatment which is economical and with least side effects.
• Full indulgence in daily activities like studies, exercise, entertainment, married life and others physical activities
• Normal or near normal lung functions.

CONTROL OF ASTHMA

Most important thing in control of asthma is education of not only doctors and their assistants but the patient and their relatives regarding:
1. Causes and factors affecting asthma
2. Drugs used for treatments, benefits, side effects and knowledge about drug delivery apparatus.
3. Precautions
4. Long term treatment plan
5. To assess the severity of disease and immediate treatment in case of deterioration.
6. When to consult the doctors

DRUGS DELIVERY SYSTEM: INHALERS

Inhalers are devices used to inhale the drug with each breath. In this way the amount of drug required is much less than taken orally or via injection but more effective and less effect on other systems of body, hence very few side effect.

There are following ways to deliver the drug via inhalation

1. Dry powder inhaler (DPI) – rotahaler, dischaler, perihaler, and multihaler.
2. Spray inhaler : Metered dose inhaler (MDI) with or without spaces
3. Nebulizer

DRUGS AVAILABLE FOR TREATMENT OF ASTHMA

Relievers drugs :
These medicine dilate the respiratory tract and relieves obstruction to cause relief in symptoms. This effect persists for 4-6 hours . Drugs like salbutamol, levosalbutamol, terbutaline (blue capped MDI/Rota Capsule), ipratropium bromide (Green cap) inhaler are good for this purpose.

Preventors drugs:

Long term treatment providing better control of asthma and reducing the frequencies of attacks. These are anti inflammatory corticosteroids e.g. Beclomethasone, Butenamide, Fluticasone, Mometasone etc (Red/Brown Cap MDI or Rota Caps) and bronchodilators like salmeterol, Formetrol (Blue), Tiatropium Bromide (Green) etc.

FACTS REGARDING ASTHMA TREATMENT

1. Preventor grugs should be effectively used in the treatment so that need of reliever medication is reduced in doses & frequency.
2. Use of inhalers which is most effective way of drug intake.
3. Inhalers have no adverse effect on pregnancy and lactation
4. Inhalers have least side effect
5. Old age, child and severe patient should use spacer with MDI. In younger children & fragile elderly patients baby mask can also be used with spacer.

SYMNPTOMS INDICATING SEVERITY OF ASTHMA

Repeated difficulty in breathing – noisy breathing cough, affecting sleep, difficulty in breathing in walking few steps, frequent requirement of drugs indicate severe asthma and doctor should be consulted immediately without wasting time as it can be dangerous.

THINGS TO REMEMEBER DURING ATTACKS OF ASTHMA

1. Do not get panicy.
2. Take deep breath.
3. Take the drugs prescribed by doctors (e.g. blue capped salbutamol or salbutamol + ipratropium bromide combination inhaler).
4. If available salbutamol solution with nebuliser can be used at home.
5. Peak flow meter use if doctors have asked to do so.

FOR NORMAL AND HEALTHY LIFE

1. Full knowledge of asthma to patient and relatives.
2. Don’t initiate self treatment, consult your doctor.
3. Avoid the factors initiating the attacks.
4. Avoid cold/icy drinks, spicy food.
5. Brush your teeth/gargles at night i.e. oral hygiene.
6. Exercise and Yoga as advised by doctors.
7. Drink plenty of water and light and timely dinner.
8. Do not stop treatment without consulting doctors, even if symptoms does not occur.
9. Regular periodical assessment of severity of disease & response to treatment by the doctor so as to reduce drug doses.
10. If possible with the help of peak flow meter you may keep self assessment of severity of asthma.

ASTHMATIC’S LIVING AT HOME

1. Avoid unnecessary furniture and articles in the room to prevent dust deposition.
2. Keep the house clean and insect free.
3. Keep carpets clean or avoid there use.
4. Avoid dusting – use wet cloth for wiping and cleaning. Use vacuum cleaner if affordable.
5. Don’t allow pets to come near.
6. Don’t smoke and avoid exposure to smoke due to passive smoking
7. Take balanced nutritious diet. This is a misconception that exacerbation or causation of asthma is caused by milk & milk products, fruits, vegetables and many eatables. It is very rare. Do not avoid any food items until unless it is proved in an individual to cause asthma.
8. Calorie intake should be balanced to avoid obesity.
9. Studies suggest that obesity aggravate asthma, more-ever obese people show slow response to treatment. Some drugs like corticosteroids used in asthma can cause increase in weight if used for long duration in high doses.
10.Keep your bed dust free and clean. Avoid synthetic linen.
11.Avoid using deodorants, perfumes, perfumed swabs, scent etc.
12.Keep proper ventilation of house. Avoid dust, smoke and pollution.
13.Cover your nose and mouth with cloth while driving, dusting or during ride on a vehicle etc.
14.Kitchen should be well ventilated. Burner to be so placed that gases & fumes go away from the working person. Use exhaust fans, chimney etc in kitchen (if affordable).

PROBLEMS IN TREAMTENT OF ASTHMA

1. Financial: More than half of the people require treatment for life long or intermittently. Expenditure of Rs. 350-500 is expected per month. B.P.L. card provide some relief to poor people in this regard by providing free of cost medicine to them in government hospitals.
2. Lack of knowledge about asthma amongst some doctors, their helpers, patients and their relatives.
3. Work Load: Excess work load in government hospitals do not allow to pay proper attention on asthma patients.
4. Increasing pollution, changing life style.

SOLUTIONS

1. By reducing the tax on asthma medicines, cost of treatment can be reduced.
2. Educating people via mass media, newspapers, radio by government agencies, doctors, NGOs etc.
3. Pollution control
4. To adopt concept of asthma nurse/asthma teacher/asthma educator to educate the patient in hospitals, general public and school children about asthma
5. To start “asthma control” programs at national level similar to T.B. control, blindness control, immunization, antenatal care & family welfare programs etc.

Modern treatment of asthma provide symptoms free, active & productive near normal Life