Asthma: In my practice Bangladesh Dr GM Monsur Habib

Bangladesh Demographic Profile 2014-15 Area: 147570 sq km Population: 163 900 501 Asthma Prevalence: 6.9% Total Asthmatics in Bangladesh: 11,473,000 Asthmatics in Practice Zone: 2,551,958 Catchment area of my practice: 42056 Km2

1505-1520: In Bangladesh, Dr Monsur Habib My Practice software

Reception & Registration Basic Data Collection My Practice Protocol Two Shift Practice: Morning Evening Counseling Room Waiting area Video/Poster Consultation Room Prescription Lung Function Test

Recording Personal Data in the practice software Reception and Registration Recording Personal Data in the practice software Preparing file with patient demographics: Weight & Height PEF by Peak Flow meter PIF by In-Check Dial BP, RR, Pulse, Temperature & SpO2 ACT (for follow-up patients) SGRQ (If asked by physician)

Video and poster display on Asthma/COPD Aim: To improve health literacy & tuned

Initial Diagnosis of Asthma in my practice: Variable symptoms + Variable airflow limitation (History) (Objective Tests) Conventional Asthma specific History taking, Physical Examination Development of a trust by listening the concerns of patient and assuring to deliver the best possible service Determine the probability of Asthma and perform objective tests Consultation Room

Visit to visit variation History suggest asthma ICS Trial 4 weeks Visit to visit variation Test for variable Airflow limitation Measure FEV1/PEFR <80% predicted or Wheezing >80% predicted & No Wheezing Serial Peak Flow No Yes Do Reversibility Test No Do Exercise challenge Test Yes No Yes Do Steroid Reversibility Test Asthma Asthma Consider other Diagnosis No Yes

Spirometry by Trained coach Reversibility test: Pre: 1.65 L (FEV1) Post: 2.69 L (FEV1) Reversed by:1004 ml & 63% After 5 mg salbutamol therapy by nebulizer

Diagnostic difficulties Patterns of childhood asthma Asthma in children Diagnosis in children Clinical features that increase the probability of asthma Typical symptom pattern Personal History of Atopic Diseases (AD) Family history of AD or Asthma Widespread wheeze Response to Asthma Therapy High probability of asthma – diagnosis of asthma is likely Start a trial of treatment Review and assess response Reserve further testing for those with poor response. Under 5’s can’t blow reliably Many illnesses mimic Asthma Diagnostic difficulties

Combination of Sx & presence of AD or parental H/O asthma Combination of Sx & presence of AD or parental H/O asthma plus positive therapeutic trial with ICS Combination of Sx & presence of AD or parental H/O asthma Single or few Sx Healthy or other diseases Asthma Ref: Pedersen S. Preschool asthma – not easy to diagnose. Prim Care Resp J 2007;16(1):4-6.

Is it occupational Asthma? Children are not out of occupational risk. Working in the Bidi factory We ask about workplace exposure Is it occupational Asthma?

Assessment of Asthma Day-time Sx Night-time Sx Need of reliever Activity limitation Poor cntr. Symptom Control Part cntr. Well cntr. Risk estimation FEV1 medication side-effects, history of ≥1 exacerbations in 12 mo poor adherence, incorrect inhaler technique, smoking, and blood eosinophilia.

Pharmaco-therapy of Asthma Standard Therapy For poor patients Diagnosis Symptom control & risk factors (including lung function) Inhaler technique & adherence Patient preference We prefer Economic Schedule with SMART therapy and Rescue Oral Steroid as per need REVIEW RESPONSE ASSESS ADJUST TREATMENT Symptoms Exacerbations Side-effects Patient satisfaction Lung function Asthma medications Non-pharmacological strategies Treat modifiable risk factors STEP 5 STEP 4 Refer for add-on treatment e.g. tiotropium,* omalizumab, mepolizumab* STEP 3 PREFERRED CONTROLLER CHOICE STEP 1 STEP 2 If rescue needs more than twice a year: Provide add on therapy: Montelukast Theophylline Med/high ICS/LABA Low dose ICS/LABA** Low dose ICS Other controller options Consider low dose ICS Leukotriene receptor antagonists (LTRA) Low dose theophylline* Med/high dose ICS Low dose ICS+LTRA (or + theoph*) Add tiotropium* High dose ICS + LTRA (or + theoph*) Add low dose OCS As-needed short-acting beta2-agonist (SABA) As-needed SABA or low dose ICS/formoterol# RELIEVER • Provide guided self-management education (self-monitoring + written action plan + regular review) • Treat modifiable risk factors and comorbidities, e.g. smoking, obesity, anxiety • Advise about non-pharmacological therapies and strategies e.g. physical activity, weight loss, avoidance of sensitizers where appropriate • Consider stepping up if … uncontrolled symptoms, exacerbations or risks, but check diagnosis, inhaler technique and adherence first • Consider stepping down if … symptoms controlled for 3 months + low risk for exacerbations. Ceasing ICS is not advised. REMEMBER TO... GINA 2016, Box 3-5 (1/8) © Global Initiative for Asthma

Picking up the concerns Counseling and negotiating with the patient for long-term therapy on Asthma Patient education What is asthma? What are the Tx options? Patient’s preference Inhaler techniques Misbeliefs How to cope with? Picking up the concerns

Exhaled Breath Temperature (EBT) measurement Monitoring We are looking for cheaper way of measuring airway inflammation Need validation study Is it a substitute of Exhaled NO?

Management Pollicy of acute exacerbation Trained senior nurse keep an eye on the entry point of the clinic to suspect any patient with emergency: Warning signs: Assess for determining the severity Ask doctor to join the assessment Moderate: start Tx Severe: Try Tx Life threatening: Immediate Hospitalization Is it asthma? Risk factors of asthma death? Severity of exacerbation? MILD or MODERATE Talks in phrases, prefers sitting to lying, not agitated Respiratory rate increased Accessory muscles not used Pulse rate 100–120 bpm O2 saturation (on air) 90–95% PEF >50% predicted or best

SEVERE Talks in words, sits hunched forwards, agitated Respiratory rate >30/min Accessory muscles in use Pulse rate >120 bpm O2 saturation (on air) <90% PEF ≤50% predicted or best

First-Aid Asthma: Rule of Five

We have well recorded data in practice software Research in our practice: National Asthma Prevalence Study BOLD-BD Detection of risk factors of Asthma Grading COPD in other useful way We have well recorded data in practice software Validation of SpiroSmart

Take-Home message from: Training & Continued Professional Development: Take-Home message from: IPCRG World Conference Education for Health UK NAPCON India APSR PULMOCON Bangladesh Attending regional short course training on Asthma

Patients registered from 4th Jan to 23rd May 2016 (2142) (198) (326) Male =1412 Female = 1253 47% 53%

We have included COPD with Asthma in Asthma group (467) (1180) (327) (150) (18) We have included COPD with Asthma in Asthma group

We also conduct Practice audit Team meeting and Clinical meeting with colleagues We also conduct

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