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ASTHMA CLINIC DETECTION IN EARLY STAGES (OPTIMAL TREATMENT PREVENTION OF CHRONIC ASTHMA AND ITS CONSEQUENCES)

CH Asrani, Pooja Mehta

Family Physicians, Vidyanagari, Mumbai 400 098.

COMPREHENSIVE ASTHMA MANAGEMENT

What is new about Asthma Clinic?

Even though all of us have been treating asthma in past, by adding peak flow meter/ spirometer and a nebulizer, we can offer better services for comprehensive asthma management.

What does this involve?

At registry, a detailed history is taken and patientís complete blood count, X-ray chest PA view and spirometry is done. Depending on the findings of all the checks done patientís treatment plan is drawn and based on history he is given a list of Dos and Doníts.

What is patientís advantage of Asthma clinic?

As the disease has no cure, control is the best way out, he will learn to live with asthma. He will get help to lead a near normal life. He will understand your problem, its cause and prevention. Special advice about asthma with other diseases, in pregnancy, care while going to a new place etc. will also be provided. In an emergency nebulizer or even intravenous medicines will be made available to him. Since his record will be maintained, it will be easy for you to manage the case.

What can I charge?

The enrolment with detailed history, Blood tests, X-ray chest and spirometry should be around Rs. 500/- only. Monthly visits with spirometry should be Rs 100/-. Any extra service should be billed at normal charges.

PROFORMA

Name -                                                              Age -

Address -

Occupation -

(current and previous)

History -

a. Age

b. Duration of disease

c. Frequency of attacks

d. Course and severity of previous attacks? Mild : (Moderate : Severe)

e. Ever hospitalized Yes/No. (If Yes how many times in a year).

Last admission

f. Recurrent episodes of

* cough

* dyspnoea

* wheeze

* exercise intolerance

* bronchitis

* rhinitis

* conjunctivitis

* atopic dermatitis

g.List (with dosages of all the drugs administered)

Is the patient on -

* Propranolol and other beta blockers

* Aspirin

* NSAIDs : Ibuprofen/ Mefenamic acid/ Diclofenac Na/ Flurbiprofen

* Histamine

* Methacholine

* Acetylcysteine

* Captopril, Enalapril

* Any nebulized medication

h. Precipitating factors present (Please mark exposure to known allergens or irritants

Yes/No (If Yes, Please specify)

- URTI

- Chest infection (Viral or Bacterial)

- Omitting regular medication yes (no)

- If yes, oral steroid; (Inhaled steroid (overuse of b agonist)

- Emotional stress

- Cold air

- Exercise

- No clear precipitating cause

Past History

Personal History

SMOKING : Yes/No : (If Yes, Frequency/day/for months/ for years)

If quit now, since when

Passive smoking : Yes/No : If yes, Details -

Tobacco Chewing : Yes/No : If Yes, times for months/ years

Alcohol : Yes/No : If Yes, Social/ Habitual.

Frequency for months/ years

Diet : Veg/ Mixed/ Veg+Eggs

Sleep : Well/ disturbed

Micturition

Bowels : Normal/ Constipated

Family History (trace the family tree on both paternal and maternal side)

Physical examination - (should assess the adequacy of air exchange)

a. Vital signs - Tachypnoea

- Tachycardia

- abrupt decline in RR

- cyanosis

- pallor

b. Pulsus Paradoxus

c. Breath sounds quality

- degree of dyspnoea

- retractions

- use of accessory muscles

d. Hydration

e. Subcutaneous emphysema

f. Mental status - altered state may denote, impairment of gas exchange

g. Atopic predisposition - oedema of nasal mucosa

- allergic rhinitis

- eczema

Lab Investigation - Blood investigations

Hb; WBC total; P; L; E; M; ESR

- IgE levels (if done)

- Chest X-ray

- S theophylline levels in pts on theophylline

PFT studies

DATE

Expected; PEFR; FVC; FEV1; FVC/ FEV1

Therapy Goals

1. Reverse bronchospasm

2. Minimise symptoms / hospitalization / absenteeism from school or work

3. Maximise productivity / normal activity

Patient should be aware of

1. Precipitants to avoid

2. Drugs to be titrated according to symptoms/ PEFR

3. Prophylaxis to minimise expected exacerbations

Spirometric findings

Name : Ms BS Age : 34

Height (in metres) : 1.6 Date : 10/7/99

Baseline

Parameters and expected values

after nebulization

FVC - 3.29

FEV1 - 2.85

FEV1/ FVC ratio -82.4

PEFR - 398

Average

Nebulization

It is one of the ways in which medication can be inhaled in cases of asthma; the other two being aerosol systems and dry powder systems.

Advantages

1. This is very useful in children and in acute severe asthma where the patient is very breathless because it does not require any hand to mouth co-ordination as with other inhalers. Tidal breathing is adequate for the purpose.

2. High doses of drug can be given (Table 1).

Disadvantages

1. High doses may result in toxicity. This also proves more expensive for the patient as a larger amount of drug is required as there is a lot of wastage.

2. Risk of transmitting air borne and gram negative infections especially where cleaning is not adequate like municipal hospitals.

3. It requires a power supply, therefore the patient canít carry it with him

A Questionnaire for the Asthmatic

1. How long have you had asthma?

2. Do you recall your first asthma attack?

TABLE 1
Comparison of drug doses
Drug
Inhaled Aerosol
Inhaled Powder
Nebulizer
Salbutamol
100 microgram
100-200 microgram
1-5mg/ml
Terbutaline
250 microgram
500 microgram
2.5mg/ml
Beclomethasone
100-200 microgram
50 microgram/ml
    

 

TABLE 2
Usual doses of Nebulization liquid
Age
Respiratory Solution
Dilution
3 months - 6 months
0.2 ml. Ipravent
2 ml. Normal saline
6 months - 1 Year
0.25 ml. Salbutamol
2.5 ml. N.S.
1 Year - 3 Years
0.3 ml. Salbutamol
3 ml. N.S.
3 Years - 6 Years
0.4 ml. Salbutamol
4 ml. N.S.
6 Years - 12 Years
0.5 ml. Salbutamol
5 ml. N. S.
Adult
1 ml. Salbutamol
ml. N. S.

3. Did it develop following another attack?

4. Do you have any idea what a precipitating factor might have been?

5. Did you cough before the attack?

6. Since this first attack, have you developed chronic asthma or do you experience intervals free of symptoms between attacks?

7. How long do these intervals last?

8. Do the attacks tend to develop during certain seasons or in certain places, at home, for example, or at your place of work?

9. Does cold air precipitate an attack?

10. Are the asthma attacks associated with other factors such as menstruation, pregnancy, smoking, excitement, coughing?

11. How many asthma attacks did you have during the previous year and how long did each one last?

12. When was your last attack?

13. Does your asthma tend to develop during the night or during the day?

14. If it develops during the day, can you still continue working?

15. Can you walk at a normal rate without developing breathlessness?

16. How many flights of stairs can you climb without pausing?

17. If you have asthma at night, about how many times do you awaken short of breath?

18. Can you physically exert yourself as you wish during an interval free of symptoms?

19. Do you experience attacks of breathlessness following physical exertion (walking, bicycling, swimming)?

20. Do you cough during or following an asthma attack? Or does coughing provoke an asthma attack?

21. Do you cough at night?

22. How often do you wake up due to coughing?

23. How long do you cough in the morning after waking?

24. Do you cough up sputum?

25. What does the sputum look like?

26. What is the amount you cough up in 24 hours (approx tablespoon, cup)?

27. Do you develop a running nose or fits of sneezing, before / after breathlessness?

28. Have you ever undergone skin testing for allergies (for example, pollen dust, house dust, fungus spores)?

29. What was the result?

30. Have you noticed that house dust worsens your condition, for example, when making beds, vacuum cleaning or at beginning of the summer?

31. Do you keep pets at home?

32. Do foodstuffs provoke an attack?

33. When was the last time you had a chest x-ray?

34. What was the result?

35. What kind of medication have you taken against asthma or cough?

36. Which drugs helped you; which ones did not?

37. Did you notice any side effects of the medication?

38. Do you carry inhalers / aerosols in your pocket? If yes, how many times in 24 hours you use it and how many inhalations each time?

39. Have you taken cortisone in recent past? If yes, oral or inhaled?

40. If yes, which compound, how many tablets per day, which dose?

41. Have you ever taken antihistamines (antiallergics); if so, which ones?

42. Have you ever been treated with injections? If yes, intramuscular or intravenous?

43. Do you ever take aspirin or similar painkillers?



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