Asthma bronchiale (AB) Chronic Obstructive Pulmonary Disease(COPD) Case studies Jana Vinklerová Asthma Bronchiale • Asthma is one of the most common chronic diseases in the world • Around 300 million people in the world currently have asthma • Global prevalence is increasing by 50% each decade • Considerable economic cost ➢Direct medical costs (hospital admissions, cost of pharmaceuticals etc.) ➢Indirect medical costs (time lost from work and premature death) What is asthma? Asthma is a chronic lung-disease • Underlying inflammation or swelling • Increased mucus production and • Contraction of muscles around the airways, or bronchospasm Inflammation in asthma leads to symptoms • Chronically inflamed airways become hyperresponsive to a variety of stimuli and obstructed by bronchoconstriction, edema, excess mucus production, and infiltrating inflammatory cells • The goal of asthma treatment is to suppress airway inflammation Symptoms Inflammation Asthma symptoms • Coughing (nightime or early morning) • Wheezing • Chest tightness • Shortness of breath • Excessive fatigue Causes • The exact cause of asthma is not known, it is thought that a variety of factors interacting with one another ➢Parents with asthma ➢Atopy ➢Childhood respiratory infections ➢Exposure to allergens or infections while the immune system is developing Asthma Triggers • A variety of things can cause asthma symptoms to appear ➢Allergens ➢Irritants – air pollution, hemicals and strong smells ➢Food and drinks ➢Medicines ➢Physical activity ➢Upper respiratory infections (viral) ➢Strong emotions ➢Cold air ➢Stress Diagnosis Based on: • Medical history – family history, atopy, symptoms… • Spirometry - test lung function (FEV1, FVC, PEF) • Allergy testing – antibody IgE Asthma Attacks If one or more of the following symptoms are present • Coughing or wheezing • Difficulty breathing, shortness of breath • Difficulty in talking and walking due to shortness of breath • Chest tightness Asthma Management Goals - tailor to meet individual needs • Achieve and maintain control of symptoms • Maintain normal activity levels, including exercise • Maintain pulmonary function as close to normal levels as possible • Prevent asthma exacerbations • Avoid adverse effects from asthma medications • Prevent asthma mortality Asthma control • Despite the availability of effective therapies, asthma control is suboptimal for many patients in Europe • The majority of patients with asthma continue to experience poor control and significant symptoms ➢About 55 % • Optimal asthma control depends on many more factors than good medication alone. Compliance plays a crucial part. Medications to Treat Asthma Two major categories of medications are • Long-term control (called controllers) ➢Taken daily over a long period of time ➢Used to reduce inflammation, relax airway muscles, and improve symptoms and lung function Inhaled corticosteroids (budesonide, fluticasone, ciclesonide, beclomethasone, momethasone) LABA (formoterol, salmeterol, vilanterol) Leukotriene modifiers (montelucast, zafirlucast) Anti IgE (omalizumab) • Quick relief (called rescue medicines) ➢Used in acute episodes (immediate relief) SABA/SAMA (salbutamol, ipratropium) Stepwise asthma management Modern vs traditional asthma treatment with LABA+ICS Case study – asthma patient 21 year old, atopic patient comes to a general practitioner with breath difficulties and cough. GP indicates Ventolin inhaler and antibiotics. Ventolin – what is active substance and the mechanism of action? Is the approach correct? Is the GP‘s approach correct? What should GP focus on in anamnesis? Which diseases should be considered? Which exams can GP provide? GP suspects asthma bronchiale Next step of the GP? ➢Indication of relief therapy What is the mechanism of action? ➢Indication of inhaled corticosteroids  Which corticosteroids do you remember?  What is their mechanism of action? ➢ Referral to specialists – pulmology, allergology Continuing case study – at the pulmologist The pulmologist diagnosed moderate persistent asthma bronchiale. How can we diagnose asthma and based on what? What tratment approach would you suggest? Continuing case study – at the pulmologist … moderate persistent asthma bronchiale Pulmologist indicated free combination of budesonide 200mcg and formoterol 6 mcg (2-0-2) plus salbutamol Why did he indicate the therapy? What does „free combination“ mean? Continuing case study – at the pulmologist …moderate persistent asthma bronchiale The patient still has uncontrolled asthma despite the treatment… How is uncontrolled asthma characterised? Possible reasons? Is there any other treatment? Continuing case study – at the pulmologist …moderate persistent asthma bronchiale The pulmologist changed treatment to a fixed combination of budesonide/formoterol 200/6 in SMART regimen. What is the product name of the fixed combination? What is the SMART regimen? Continuing case study – at the pulmologist The patient still has uncontrolled asthma despite the treatment… What tests would be appropriate to add and why? Continuing case study – at the pulmologist Variant 1: Pulmonary hypertension was not proved. Specific anti IgE was detected. The pulmologist changed the classification to severe persistent asthma, difficult to treat asthma. What next step would you suggest? Continuing case study – at the pulmologist Severe persistent asthma, difficult to treat asthma.... The physician added omalizumab to current treatment with Symbicort Turbuhaler 200/6 (2-0-2, SMART). What is the product name? What is the mechanism of action? Who can indicated this treatment? Continuing case study – at the pulmologist Severe persistent asthma, difficult to treat asthma.... Patient is treated with Symbicort Turbuhaler 200/6 (2-0-2, SMART), Xolair 150mg (every fourth week) …still not under control. What else can be added? Continuing case study – at the pulmologist Variant 2: Patient is heavy smoker. Bronchodilatation test is irreversible. What can we consider? Continuing case study – at the pulmologist The pulmologist changed classification of the disease to ACOS (Asthma COPD Overlap Sy). What treatment would you suggest? Case study – overlap COPD and asthma (ACOS) The pulmologist added tiotropium to the current treatment with Symbicort Turbuhaler 200/6 (2-0-2, SMART). Why this drug? What is the mechanism of action? What is the product name? Chronic Obstructive Pulmonary Disease • A progressive disease that affects the lungs, making it difficult to breathe • Progressive lung diseases which include: ➢Emphysema ➢Chronic bronchitis ➢Irreversible bronchoconstriction ➢Severe bronchiectasis Lung with COPD Definition of COPD What is COPD? Common, preventable and treatable disease AIRFLOW LIMITATION CHRONIC INFLAMMATION Small airways disease Parenchym al destructio n Comorbidities, Exacerbations and Chronic bronchitis Causes Prevalence HIGHER PREVALENCE IN…. SMOKERS than in non-smokers, although prevalence is between 3-11% in never-smokers MEN than in women OVER 40 YEARS OLD than in younger people. Highest prevalence is found among those over the age of 60 Risk factors for COPD COPD phathophysiology Symptoms • Breathlessness • Abnormal sputum (a mix of saliva and mucus in the airway) • A chronic cough • Daily activities can become very difficult as the condition gradually worsens COPD exacerbations Impact on symptoms and lung function Negative impact on quality of life Increased economic costs Accelerated lung function decline Increased Mortality Consequences of COPD exacerbations Goals of therapy Diagnosis of COPD Spirometry for COPD Diagnosis and Classification of Severity Classification of COPD Severity by Spirometry Combined COPD assessment Assessment of COPD includes Phenotypes of COPD Therapy Therapy Therapy Therapy Therapy Therapy Case study – patient with COPD Patient comes to a hospital following newspaper advertisement (Is your breathing difficult? Have your lung function tested). PA: ex-smoker, hypertensis Drugs: Tenormin 100mg OD CD: Last 3 months cough and increased sputum production. During weather changes and stress he has breathing difficulties. Also he has breathing difficulties when walking up hill. What tests would you suggest? Case study – patient with COPD COPD diagnosed, bronchitic phenotype. Pulmologist indicated Formovent 12mcg (1-0-1) and combination Atrovent a Ventolin as needed. What kind of drugs are those? What are their mechanism of action? Is the suggested treatment satisfactory? Case study – patient with COPD Formovent 12mcg (1-0-1) and combination Atrovent a Ventolin as needed. At bronchitic phenotype is suitable to add mucolytic/expectorant drugs - Do you know any? - Why is it not possible to prescribe antitussives? Can it be appropriate to use other treatment and why? Case study – patient with COPD Formovent 12mcg (1-0-1) and combination Atrovent a Ventolin as needed. Is the suggested treatment suitable for patient with hypertension treated with Tenormin? ➢ What is the active substance and mechanism of action? Which interactions of the treatment can be in relation to suggested COPD treatment? Is there more suitable way of treatment of both diseases?