BRONCHIAL ASTHMA FINAL

Views:
 
Category: Entertainment
     
 

Presentation Description

No description available.

Comments

Presentation Transcript

BRONCHIAL ASTHMA:

BRONCHIAL ASTHMA PEARLS 7/10/2012 1 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 2

Amr Badreldin Hamdy, MD FCCP:

Amr Badreldin Hamdy , MD FCCP Prof of Pulmonary Medicine Banha University , EGYPT Pulmonary Consultant NEW CAPITAL MEDICAL CENTRE, ABU DHABI 7/10/2012 3 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

I can write better than anybody who can write faster, and I can write faster than anybody who can write better . - A. J. Liebling 7/10/2012 4 Amr Badreldin Hamdy MD FCCP

OBJECTIVES:

OBJECTIVES Define bronchial asthma. Identify the clinical picture of BA. Identify the trigger factors of BA. Diagnose BA. Is it BA? Treatment of BA. Prognosis of BA. 7/10/2012 5 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

The Egyptian Ebers Papyrus (written in hieroglyphics) prescription for asthma included mixture of herbs heated on a brick so that the sufferer could inhale their fumes . 7/10/2012 Amr Badreldin Hamdy MD FCCP 6

PowerPoint Presentation:

The word asthma is derived from the Greek word azein ( to breath hard). 7/10/2012 Amr Badreldin Hamdy MD FCCP 7

PowerPoint Presentation:

Burden of Asthma Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals Prevalence increasing in many countries, especially in children A major cause of school/work absence 7/10/2012 8 Amr Badreldin Hamdy MD FCCP

Possible Explanation for Changes in Prevalence of BA:

Possible Explanation for Changes in Prevalence of BA Indoor environment. Smoking. Family size. Pollution. Diet. 7/10/2012 AMR BADRELDIN HAMDY MD 9

Burden of Asthma-cont’d:

Burden of Asthma-cont’d The WHO has reported the annual costs of BA exceed those of TB and HIV combined due to poor asthma control and disease management. 7/10/2012 Amr Badreldin Hamdy MD FCCP 10

Burden of Asthma-cont’d:

Burden of Asthma-cont’d The evaluation of asthma costs considers both direct costs (medication and treatment) and indirect costs (loss of school or working days and decrease in productivity ). 7/10/2012 Amr Badreldin Hamdy MD FCCP 11

Burden of Asthma-cont’d:

Burden of Asthma-cont’d In Europe the estimated total cost of asthma is $21.65 billion/year as follows: Outpatient costs $4.65 billion Medications $4.4 billion Indirect costs $11.99 billion. 7/10/2012 Amr Badreldin Hamdy MD FCCP 12

DEFINITION OF BA:

DEFINITION OF BA 7/10/2012 13 Amr Badreldin Hamdy MD FCCP

Definition:

Definition Asthma is a chronic inflammatory disorder of the airway in which many cells play a role, in particular mast cells , eosinophils , and T-lymphocytes. 7/10/2012 Amr Badreldin Hamdy MD FCCP 14

Definition cont’d:

Definition cont’d In susceptible individuals this inflammation causes recurrent episodes of wheezing, breathlessness , chest tightness , and cough, particularly at night or in the early morning . 7/10/2012 Amr Badreldin Hamdy MD FCCP 15

Definition cont’d:

Definition cont’d These symptoms are usually associated with widespread but variable airflow limitation that is at least partly reversible either spontaneously or with treatment. The inflammation also causes an associated increase in airway responsiveness to a variety of stimuli. 7/10/2012 Amr Badreldin Hamdy MD FCCP 16

PowerPoint Presentation:

Source: Peter J. Barnes, MD Asthma Inflammation : Cells and Mediators 7/10/2012 17 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

We can't solve problems by using the same kind of thinking we used when we created them . - Albert Einstein 7/10/2012 18 Amr Badreldin Hamdy MD FCCP

CLINICAL PICTURE:

CLINICAL PICTURE 7/10/2012 19 Amr Badreldin Hamdy MD FCCP

Physical Examination:

Physical Examination Because of variable symptoms, the physical examination of the respiratory system may be normal. Dyspnea , airflow limitation (wheeze), and hyperinflation are likely to be present if patients are examined during symptomatic periods. Silent chest, cyanosis, drowsiness, difficult speaking, tachycardia and use of accessory muscles in severe asthma . 7/10/2012 20 Amr Badreldin Hamdy MD FCCP

Clinical Symptoms:

Clinical Symptoms Intermittent symptoms Cough Wheeze Shortness of breath Chest pain Diurnal variation Varying triggers Rescue medication use Exacerbations 7/10/2012 21 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 22 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 AMR BADRELDIN HAMDY MD 23 Stratification of the severity of an asthma attack based upon symptoms and physical examination Sign Imminent Severe Moderate Mild Breathlessness Only lying down On talking Prefers to sit up On walking Can lie down Speaking Cannot speak Words Parts of phrases Phrases Level of consciousness Breathing rate Sleepy or confused Always agitated Often >30/min Usually agitated Increased May be agitated Increased Muscle retraction Paradoxical Usually Usually No Wheezing Absent Very Strong Strong Moderate Pulse per min Bradycardia >120 100-120 < 100 Peak expiratory flow after treatment Impossible to measure <50%; <100 l/mm 50-70% Over 70%

Signs:

Signs 7/10/2012 24 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 25 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 26 Amr Badreldin Hamdy MD FCCP

Types of BA:

Types of BA Childhood onset. Adult onset. Nocturnal. Occupational. Cough variant. Exercise induced. Brittle. Aspirin sensitive . 7/10/2012 AMR BADRELDIN HAMDY MD 27

Adult-Onset Asthma:

Adult-Onset Asthma Onset of asthma for the first time in adults older than 20 ( middle age or older). It is more commonly persistent and permanent. Daily medications are often needed. Occupational exposure is an important cause of adult-onset asthma. 7/10/2012 AMR BADRELDIN HAMDY MD 28

Nocturnal Asthma:

Nocturnal Asthma There remains controversy over whether nocturnal asthma represents a distinct entity or is simply a manifestation of more severe asthma. Are the mechanistic observations in nocturnal asthma a cause of or a consequence of NA, or are they associated features that are not causally related? 7/10/2012 AMR BADRELDIN HAMDY MD 29

Postulated Mechanisms of NA:

Postulated Mechanisms of NA Airway cooling. Allergen exposure. GERD. Obesity. Increased tissue inflammation. Decreased plasma epinephrine. Decreased plasma cortisol . Increased circulating eosinophils . Increased cholinergic tone. 7/10/2012 AMR BADRELDIN HAMDY MD 30

Occupational Asthma:

Occupational Asthma OA is a disease characterized by variable airflow limitation and/or airway hyper-responsiveness due to causes and conditions attributable to a particular occupational environment and not to stimuli encountered outside the work place (Bernstein et al, 1993). 7/10/2012 AMR BADRELDIN HAMDY MD 31

PowerPoint Presentation:

7/10/2012 AMR BADRELDIN HAMDY MD 32 Common Occupations Associated with Asthma Spray painters Saw mill workers or carpenters Bakers Smelter workers Electronics workers Pharmaceutical industry workers

Cough Variant Asthma:

Cough Variant Asthma It is a type of cough with duration of more than 4 weeks without a clear etiology and which is associated with bronchial hyperactivity ( Boulet et al, 1994). Chronic cough with a good response to beta-2 sympathomimetics with no etiology and bronchial hyperactivity (Irwin et al, 1997). 7/10/2012 AMR BADRELDIN HAMDY MD 33

Criteria For CVA By The Japanese Couch Research Society:

Criteria For CVA By The Japanese Couch Research Society Isolated chronic non-productive cough lasting more than 8 weeks. Absence of history of wheezing or dyspnea , and no adventitious lung sounds on physical examination. Absence of postnasal drip. FEV1, FVC, and FEV1/FVC ratio within normal limits. 7/10/2012 AMR BADRELDIN HAMDY MD 34

Cont’d:

Cont’d Presence of bronchial hyper-responsiveness. Relief of cough with bronchodilator therapy. No abnormal findings indicative of cough etiology on chest radiography. (Fujimura et al, 2003). 7/10/2012 AMR BADRELDIN HAMDY MD 35

Exercise-Induced Asthma:

Exercise-Induced Asthma Acute lung airway narrowing that occurs during and/or after physical activity. Symptoms of wheezing and SOB generally begin within 5-20 min after the start of exercise, or 5-10 min after brief exercise has stopped. 7/10/2012 AMR BADRELDIN HAMDY MD 36

Brittle Asthma:

Brittle Asthma Type I : Characterized by a chaotic, unpredictable and wide PEFR variability (more than 40% diurnal variation for more than 50% of the time over a period of at least 150 days despite considerable medical therapy including a dose of ICS of at least 1500 ug of beclomethasone or equivalent). 7/10/2012 AMR BADRELDIN HAMDY MD 37

Brittle Asthma- Cont’d:

Brittle Asthma- Cont’d Type II : Characterized by sudden acute attacks occurring in less than three hours without an obvious trigger or background of apparent normal airway function or well controlled asthma. (Ayres et al, 1998). 7/10/2012 AMR BADRELDIN HAMDY MD 38

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 39

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 40

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 41 Common aggravating factors in Asthma Aggravating Factor Comments Rhinitis Avoidance of precipitants such as pollen Use of nasal steroids and antihistamines may be helpful Gastro Esophageal Reflux Disease Trial of proton pump inhibitor may be considered in patients with suggestive symptoms though trials have not suggested therapeutic efficacy for improving asthma control Drugs Commonly prescribed medication include aspirin, ACE inhibitors and NSAIDs All these medication should be withdrawn and replaced with available alternatives if they exacerbate symptoms Beta-Blocker should always be withdrawn Common aero-allergens Common examples include pollen, pet allergens, house dust mite and fungal spores Avoidance measures are recommended though efficacy in improving asthma control is variable

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 42 Common aggravating factors in Asthma – Cont’d Aggravating Factor Comments Smoking Smoking cessation should be strongly encouraged and referral to a smoking cessation service is recommended Occupational allergens Dust smoke and poor ventilation can all contribute to deterioration in asthma control In contrast occupational agents that have been identified in the development o f asthma include isocyanates (spray painting); flour; wood dust; glutaraldehyde (nursing); solder/colophony (welding and soldering In all cases occupational exposures should be considered and investigated appropriately. Employers have a statutory duty to provide safe employment in cases of occupational asthma

DIAGNOSIS:

DIAGNOSIS 7/10/2012 Amr Badreldin Hamdy MD FCCP 43

Asthma Diagnosis:

Asthma Diagnosis History and patterns of symptoms Physical examination Measurements of lung function Measurements of allergic status to identify risk factors 7/10/2012 44 Amr Badreldin Hamdy MD FCCP

Diagnosing Asthma:

Diagnosing Asthma What to look for: Episodic symptoms of airflow obstruction and BHR Airflow obstruction is at least partially reversible Alternative diagnoses are excluded How to Assess: Detailed medical history Physical examination (focus on upper respiratory tract, chest, skin) Spirometer to demonstrate obstruction and assess reversibility (>4 years of age Additional studies as necessary 7/10/2012 Amr Badreldin Hamdy MD FCCP 45

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 46

PEFR:

PEFR 7/10/2012 47 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 48

PER Variability:

PER Variability 7/10/2012 49 Amr Badreldin Hamdy MD FCCP

PER Recovery:

PER Recovery 7/10/2012 50 Amr Badreldin Hamdy MD FCCP

Measurement of Lung Function:

Measurement of Lung Function Spirometry : FEV1, FVC,FEV1/FVC Bronchial Provocation Test (BPT) FEV1>70% predicted Histamine,methacholine , or exercise FEV1↓≥20% at a dose of ≤16mg/ml 7/10/2012 51 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 52

PowerPoint Presentation:

7/10/2012 53 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 54 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 55 Amr Badreldin Hamdy MD FCCP

Measurement of Lung Function:

Measurement of Lung Function Bronchial Dilation Test (BDT) FEV1<70% predicted FEV1↑≥12% and 200ml, FVC↑≥15% and 200ml, after inhaling a short-acting bronchodilator 7/10/2012 56 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

Typical Spirometric (FEV 1 ) Tracings 1 Time (sec) 2 3 4 5 FEV 1 Volume Normal Subject Asthmatic (After Bronchodilator ) Asthmatic (Before Bronchodilator ) Note: Each FEV 1 curve represents the highest of three repeat measurements 7/10/2012 57 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 58 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 59 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 60 Amr Badreldin Hamdy MD FCCP

Exercise Testing:

Exercise Testing 7/10/2012 61 Amr Badreldin Hamdy MD FCCP

Provocation Test:

Provocation Test 7/10/2012 62 Amr Badreldin Hamdy MD FCCP

Pulse Oximetry:

Pulse Oximetry 7/10/2012 63 Amr Badreldin Hamdy MD FCCP

Arterial Blood Gas:

Arterial Blood G as Respiratory alkalosis , during a mild asthma exacerbation. Respiratory acidosis and hypoxemia, during a severe asthma exacerbation. 7/10/2012 64 Amr Badreldin Hamdy MD FCCP

Chest X-ray - Pneumothorax:

Chest X-ray - Pneumothorax 7/10/2012 65 Amr Badreldin Hamdy MD FCCP

Pneumomediastinum:

Pneumomediastinum 7/10/2012 66 Amr Badreldin Hamdy MD FCCP

Skin Testing:

Skin Testing 7/10/2012 67 Amr Badreldin Hamdy MD FCCP

Skin Testing-cont’d:

Skin Testing-cont’d 7/10/2012 68 Amr Badreldin Hamdy MD FCCP

Skin Testing-cont’d:

Skin Testing-cont’d 7/10/2012 69 Amr Badreldin Hamdy MD FCCP

Pros and Cons of Skin Testing:

Pros and Cons of Skin Testing 7/10/2012 70 Amr Badreldin Hamdy MD FCCP

RAST Test:

RAST Test 7/10/2012 71 Amr Badreldin Hamdy MD FCCP

DIFFERENTIAL DIAGNOSIS OF BA:

DIFFERENTIAL DIAGNOSIS OF BA 7/10/2012 72 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 73

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 74 Points to seek in the history suggesting a different or supplementary diagnosis Are the child/family really describing wheeze Upper airway symptoms – snoring, rhinitis, sinusitis Symptoms from the first day of life Very sudden onset of symptoms Chronic moist cough/sputum production Worse wheeze or irritable after feed, worse when lying down, vomiting, choking on feeds Any feature of a systemic immunodeficiency Continuous, unremitting or worsening symptoms Symptoms which disappear when the child is asleep

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 75 Points to seek in the physical examination suggesting a different or supplementary diagnosis Digital clubbing, signs of weight loss, failure to thrive Upper airway disease – enlarged tonsils and adenoids, prominent rhinitis, nasal polyps Unusually severe chest deformity (Harrison’s sulcus , barrel chest) Fixed monophonic wheeze Stridor ( monophasic or biphasic) Asymmetrical wheeze Signs of cardiac or systemic disease

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 76 More frequent diseases other than asthma which could produce wheezing in children Newborn and very young infants (0-3 month) Bronchopulmonary dysplasia Congenital malformations of the laryngeal region ( laryngomalacia , vocal cord paralysis, laryngeal angiomatosis , cysts, tumors, etc) Congenital malformations of the trachea and greater airways ( tracheomalacia , bronchomalacia , tracheal or bronchial stenosis , tracheal-esophageal fistula) Vascular rings or laryngeal membranes Older Infants (3-12 months) Croup Gastroesophageal reflux / Aspiration Cystic fibrosis Heart malformations Children older than 1 year of age Foreign body aspiration Primary ciliary dyskinesia Bronchiolitis obliterans Congenital malformations of the lung and the airways Vocal cord dysfunction (adolescents) Note: any disease may be present at any age 7/10/2012

PowerPoint Presentation:

7/10/2012 77 Amr Badreldin Hamdy MD FCCP

Severity of Asthma:

Severity of Asthma 7/10/2012 78 Amr Badreldin Hamdy MD FCCP

TREATMENT:

TREATMENT 7/10/2012 79 Amr Badreldin Hamdy MD FCCP

The Aims of Treatment:

The Aims of Treatment To control symptoms to lead a full and active life. To restore normal lung function and reduce variations in peak flow. To minimize the requirement for bronchodilator therapy and prevent exacerbations. To enable normal growth and development and avoid adverse effects of medication . 7/10/2012 Amr Badreldin Hamdy MD FCCP 80

Key Aspects In The Medical Treatment Of Asthma:

Key Aspects In The Medical Treatment Of Asthma Relationship with a primary Health Care Provider who is knowledgeable of current asthma treatment guidelines Development, sharing, and use of a personalized Asthma Action Plan or Asthma Management Plan Monitoring of symptoms with a peak flow meter and pulmonary function testing 7/10/2012 81 Amr Badreldin Hamdy MD FCCP

Key Aspects Cont’d:

Key Aspects Cont’d Catching early warning signs and referring for assessment or treatment Well asthma check-ups Every 6 months for asthma that is under control More frequently for asthma that is out of control Stepping up and down therapy as needed 7/10/2012 82 Amr Badreldin Hamdy MD FCCP

Categories of Drugs Used:

Categories of Drugs Used Bronchodilators : Inhaled beta agonists. Inhaled anti- cholinergics . Theophyllines . Long acting beta agonists. 7/10/2012 Amr Badreldin Hamdy MD FCCP 83

Cont’d:

Cont’d Preventers: Inhaled corticosteroids. Sodium chromoglycate . Nedocromil sodium. Leukotriene receptor agonists. 7/10/2012 Amr Badreldin Hamdy MD FCCP 84

Controller vs. Reliever Meds:

Controller vs. Reliever Meds Controller medication Daily medications for all persistent asthma Long term control Anti-inflammatory Reliever or Quick-relief medication Bronchodilators - As needed for all asthma severity levels Used PRN and preventative for EIA Bronchodilators Oral corticosteroid bursts 7/10/2012 85 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 86

Changing Roles of Asthma Therapies:

Changing Roles of Asthma Therapies LABAs Black box warning: may increase the risk of asthma-related exacerbations and deaths Should only be prescribed for not adequately controlled on other medications or whose disease severity warrants initiation of treatment with 2 maintenance therapies For patient ≥12 years of age not adequately controlled on low-dose ICS, the option of increasing to medium-dose ICS should be given equal weight to ICS + LABA LABA have proven efficacy when used with an appropriate dose of ICS 7/10/2012 Amr Badreldin Hamdy MD FCCP 87

Changing Roles of Asthma Therapies-cont’d:

Changing Roles of Asthma Therapies-cont’d Leukotriene modifiers More prominent role as controller treatment in asthma, particularly in adults Historically have had an excellent safety The following postmarketing adverse events have been added to the montelukast label: tremor, depression, suicidality , anxiousness The US FDA is reviewing montelukast post reports; this may take up to 9 months May be used as alternative to ICS (step 2) or add-on to ICS (steps 3, 4) Most effective for patients with mild, persistent asthma Provide benefit when added to ICS therapy but not as effective as ICS with LABAs 7/10/2012 Amr Badreldin Hamdy MD FCCP 88

Changing Roles of Asthma Therapies-cont’d:

Changing Roles of Asthma Therapies-cont’d Cromones Not among recommended Global Initiative for Asthma (GINA) asthma treatments, but still recommended by NAEPP Immunomodulators As adjunctive therapy for patients who have allergies and uncontrolled asthma at steps 5 and 6 Asthma adult (≥ 12 years of age) therapy option Black box warning for anaphylaxis 7/10/2012 Amr Badreldin Hamdy MD FCCP 89

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 90

How MDI Technology Works:

How MDI Technology Works 7/10/2012 91 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 AMR BADRELDIN HAMDY MD 92

Inhalers:

Inhalers 7/10/2012 Amr Badreldin Hamdy MD FCCP 93

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 94

Inhalers:

Inhalers Press and Breathe Breath Actuated Dry Powder Aerosol 7/10/2012 95 Amr Badreldin Hamdy MD FCCP

Methods Of Delivery :

Methods Of Delivery Medications may be given by: Metered Dose Inhaler (MDI) Dry Powdered Inhaler (DPI) Nebulizer Orally Important to review technique for all delivery methods 7/10/2012 96 Amr Badreldin Hamdy MD FCCP

Turbuhaler Use:

Turbuhaler Use Need deep, forceful inhalation May use Turbu -tester to help determine if an individual is able to use Counter (dots in window) turns red when doses running out 7/10/2012 97 Amr Badreldin Hamdy MD FCCP

Combination Medication:

Combination Medication Fluticasone + Serevent Combo corticosteroid and long acting beta-agonist 3 strengths: 100/50, 250/50, 500/50 Strengths based on Flovent doses, Serevent dose remains the same in all three strengths. Diskus Dry Powdered Inhaler Usual dosing, 1 inhalation every 12 hours Has remaining-dose counter 7/10/2012 98 Amr Badreldin Hamdy MD FCCP

Diskus Demonstration:

Diskus Demonstration Diskus Breath in deep and steady 1 breath per dose Counter tracks remaining doses 3 strengths CS/ Serevent 100 (green label), 250 (yellow label), 500 (red label) 60 doses per diskus 7/10/2012 99 Amr Badreldin Hamdy MD FCCP

Salmeterol Diskus:

Salmeterol Diskus Formoterol 7/10/2012 100 Amr Badreldin Hamdy MD FCCP

Long-acting Beta-agonists:

Long-acting Beta-agonists Salmeterol ( Diskus ) Formoterol ( DPI ) Potential adverse effects Tachycardia, tremors, hypokalemia Therapeutic issues Should not be used in place of anti-inflammatory therapy 7/10/2012 101 Amr Badreldin Hamdy MD FCCP

Short-acting Inhaled Bronchodilators:

Short-acting Inhaled Bronchodilators Albuterol Levalbuterol Pirbuterol Metaproterenol For relief of acute symptoms or as preventive treatment prior to exercise Potential adverse effects Tremors, tachycardia, headache Therapeutic issues D rugs of choice for acute bronchospasm 7/10/2012 102 Amr Badreldin Hamdy MD FCCP

Aerosol Metered Dose Inhalers and Chambers / Spacers:

Aerosol Metered Dose Inhalers and Chambers / Spacers Use a spacer with an aerosol inhaler Gets more medication into the lungs (~5 x more than MDI alone) Fewer side effects such as smaller amount of absorbed medication systemically, less oral thrush and dysphonia . F27 7/10/2012 103 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 104 Amr Badreldin Hamdy MD FCCP

How To Use Your Inhaler:

How To Use Your Inhaler 7/10/2012 105 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

Amr Badreldin Hamdy MD FCCP What Are Benefits Of Long Term Preventive Treatment Of Asthma?

PowerPoint Presentation:

Amr Badreldin Hamdy MD FCCP Improved quality of life . Reduced frequency and severity of asthma exacerbations . Reduced risk of emergency room visits . Reduced risk of hospital admission .

Cont’d:

Amr Badreldin Hamdy MD FCCP Cont’d Prevent loss of productivity from day missed at work/school. Reduce total cost of asthma treatment in the longer term. Reduce risk of death from asthma.

Asthma Control Test:

Asthma Control Test 2. During the past 4 weeks, how often have you has shortness of breath (SOB)? __ more than once a day __ 3 – 6 times a week __ not at all __ once a day __ once or twice a week 1 . In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work or at home ? __ all of the time __ some of the time __ none of the time __ most of the time __ a little of the time 7/10/2012 AMR BADRELDIN HAMDY MD 109 3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, SOB, chest tightness, pain) wake you up at night or earlier than usual in the morning? __ 4 or more nights a week __ once a week __ not at all __ 2-3 nights a week __ 2 – 3 nights a week 4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medicatio n __ 2–3 more times per day __ 2 – 3 times a week __ not at all __ 1 or more times per day __ once a week or less 5 . How would you rate you asthma control during the past 4 weeks? __ not controlled at all __ somewhat controlled __ completely controlled __ poorly controlled __ well controlled

Score:

Score Total control= 25 . Well controlled= 20-24 . Not (well) controlled= Less than 20 . 7/10/2012 Amr Badreldin Hamdy MD FCCP 110

Assessing Asthma Control (0 – 4 Years of Age):

Assessing Asthma Control (0 – 4 Years of Age) 7/10/2012 111 AMR BADRELDIN HAMDY MD Components of Control Well Controlled Not Well Controlled Very Poorly Controlled IMPAIRMENT Symptoms ≤ 2 days/w > 2 days/w Throughout the day Night time Awakenings 1x month > 1x month > 1x week Interference with normal activity None Some Extreme SABA use for symptom control ≤ 2 days/w > 2 days/w Several times per day RISK Exacerbations 0-1x year 2-3x year > 3 x year Treatment-related adverse effects Medication side effects can vary in intensity from none to troublesome or worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.

PowerPoint Presentation:

7/10/2012 AMR BADRELDIN HAMDY MD 112 Assessing Asthma Control (5 - 11 Years of Age) Components of Control Well Controlled Not Well Controlled Very Poorly Controlled IMPAIRMENT Symptoms ≤ 2 days/w but not >1x on each day > 2 days/w or multiple times ≤2 days/w Throughout the day Night time Awakenings ≤1x month ≥ 2x month ≥ 2x month Interference with normal activity None Some Extreme SABA use for symptom control ≤ 2 days/w > 2 days/w Several times per day FEV1 or peak flow FEV/FVC >80% predicted / personal best >80% 60-80% predicted/ personal best 75-80% <60% predicted/ personal best <75% RISK Exacerbations 0-1x year > 2x year Consider severity and interval since last exacerbation Reduced lung growth Evaluation requires long-term follow up Treatment-related adverse effects Medication side effects can vary in intensity from none to troublesome or worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.

PowerPoint Presentation:

7/10/2012 AMR BADRELDIN HAMDY MD 113 Assessing Asthma Control (≥12 Years of Age) Components of Control Well Controlled Not Well Controlled Very Poorly Controlled IMPAIRMENT Symptoms ≤ 2 days/w > 2 days/w Throughout the day Night time Awakenings 1x month > 1x month > 1x week Interference with normal activity None Some Extreme SABA use for symptom control ≤ 2 days/w > 2 days/w Several times per day FEV1 or peak flow >80% predicted / personal best 60-80% predicted/ personal best <60% predicted/ personal best ATAQ 0 1-2 3-4 ACQ ≤0.75 ≥1.5 N/A ACT ≥20 16-19 ≤15 RISK Exacerbations 0-1x year 2-3x year > 3 x year Treatment-related adverse effects Medication side effects can vary in intensity from none to troublesome or worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.

PowerPoint Presentation:

Part 4: Long-term Asthma Management Stepwise Approach to Asthma Therapy - Adults Reliever: Rapid-acting inhaled β 2 - agonist prn Controller: Daily inhaled corticosteroid Controller: Daily inhaled corticosteroid Daily long-acting inhaled β 2 - agonist Controller: Daily inhaled corticosteroid Daily long –acting inhaled β 2 - agonist plus (if needed) When asthma is controlled, reduce therapy Monitor STEP 1: Intermittent STEP 2: Mild Persistent STEP 3: Moderate Persistent STEP 4: Severe Persistent STEP Down Outcome: Asthma Control Outcome: Best Possible Results Alternative controller and reliever medications may be considered (see text). Controller: None -Theophylline- SR -Leukotriene -Long-acting inhaled β 2 - agonist -Oral corticosteroid 7/10/2012 114 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

Stepwise Approach to Asthma Therapy: Adults Step 1: Intermittent Asthma None required Rapid-acting inhaled  2 -agonist for symptoms (but < once a week) Rapid-acting inhaled  2 -agonist, cromone, or leukotriene modifier before exercise or exposure to allergen Continuously review medication technique, compliance and environmental control Review treatment every three months. Step up if control is not achieved; step down if control is sustained for at least 3 months Preferred treatments are in bold print Daily Controller Medications Reliever Medications 7/10/2012 115 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

Inhaled glucocorticosteroid (< 500 μ g BDP or equivalent) Other options ( order by cost ): sustained-release theophylline, or Cromone, or leukotriene modifier Rapid-acting inhaled  2 -agonist for symptoms (but < 3-4 times/day) Other options: inhaled anticholinergic, or short-acting oral  2 -agonist, or short-acting theophylline Continuously review medication technique, compliance and environmental control. Review treatment every three months Step up if control is not achieved; Step down if control is sustained for at least 3 months Preferred treatments are in bold print Stepwise Approach to Asthma Therapy: Adults Step 2: Mild Persistent Asthma Daily Controller Medications Reliever Medications 7/10/2012 116 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

Inhaled glucocorticosteroid, (200 – 500 μg BDP or equivalent) plus long-acting inhaled β 2 agonist Other options (order by cost) : Inhaled glucocorticosteroid (500 – 1000 μg BDP equivalent) plus sustained-release theophylline, or Inhaled glucocorticosteroid (500 – 1000 μg BDP equivalent) plus long-acting inhaled β 2 - agonist, or inhaled glucocorticosteroid at higher doses (> 1000 μg BDP equivalent), or Inhaled glucocorticosteroid (500 – 1000 μg BDP equivalent) plus leukotriene modifier Rapid-acting inhaled  2 -agonist for symptoms (but < 3 - 4 times/day) Other options: inhaled anticholinergic o r short-acting oral  2 -agonist or short-acting theophylline Continuously review medication technique, compliance and environmental control. Review treatment every three months. Step up if control is not achieved; Step down if control is sustained for at least 3 months. Preferred treatments are in bold print. Stepwise Approach to Asthma Therapy: Adults Step 3: Moderate Persistent Asthma Daily Controller Medications Reliever Medications 7/10/2012 117 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

Inhaled glucocorticosteroid, (> 1000 μg BDP or equivalent) plus long-acting inhaled β 2 agonist plus one or more of the following, if needed (order by cost) : sustained-release theophylline, or leukotriene modifier or oral glucocorticosteroid Rapid-acting inhaled  2 -agonist for symptoms (but < 3-4 times/day) Other options: inhaled anticholinergic o r short-acting oral  2 -agonist or short-acting theophylline Continuously review medication technique, compliance and environmental control. Review treatment every three months. Step up if control is not achieved; Step down if control is sustained for at least 3 months. Preferred treatments are in bold print. Stepwise Approach to Asthma Therapy: Adults Step 4: Severe Persistent Asthma Daily Controller Medications Reliever Medications 7/10/2012 118 Amr Badreldin Hamdy MD FCCP

Therapies Not Recommended For Treating Attacks :

Therapies N ot R ecommended F or T reating A ttacks Sedatives (strictly avoid) Mucolytic drugs (may worsen cough) Chest physical therapy/physiotherapy (may increase patient discomfort) Hydration with large volumes Antibiotics (do not treat attacks but are indicated for patients who also have pneumonia or bacterial infection such as sinusitis). 7/10/2012 119 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

Component 4: Asthma Management and Prevention Program Controller Medications Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β 2 -agonists Systemic glucocorticosteroids Theophylline Cromones Long-acting oral β 2 -agonists Anti- IgE Systemic glucocorticosteroids 7/10/2012 120 Amr Badreldin Hamdy MD FCCP

Controllers Inhaled Corticosteroids:

Controllers Inhaled Corticosteroids Reduces airway swelling over time, decreases airway hyper-responsiveness Must be taken daily, even if no symptoms Will not relieve acute asthma symptoms 7/10/2012 121 Amr Badreldin Hamdy MD FCCP

Inhaled Corticosteroids Cont’d:

Inhaled Corticosteroids Cont’d When used consistently over time will prevent/control inflammation and acute episodes Dose/strength may need to be increased or decreased depending on season of the year (step up / step down) Inhaled steroids start to work in days to weeks, oral steroids within 6-24 hours 7/10/2012 122 Amr Badreldin Hamdy MD FCCP

ICS Efficacy, Safety and Limitations:

ICS Efficacy, Safety and Limitations Efficacy Reduced asthma symptoms, improved quality of life, improved lung function, decreased airway hyperresponsiveness , controlled airways inflammation, reduced frequency and severity of exacerbations, reduced asthma mortality Side Effects Long-term treatment with high doses; easy bruising, adrenal suppression, decreased bone mineral density In children: small, possibly transient reductions in growth velocity Limitations Do not affect long-term airway remodelling Do not increase likelihood of outgrowing asthma 7/10/2012 Amr Badreldin Hamdy MD FCCP 123

Steroid Phobia: Unfounded!:

Steroid Phobia: Unfounded! Inhaled steroids in doses most often prescribed are very safe Inhaled meds delivered directly to lungs where they are needed Little systemic absorption if proper technique used 7/10/2012 124 Amr Badreldin Hamdy MD FCCP

Non-Steroidal Anti-inflammatory:

Non-Steroidal Anti-inflammatory Cromolyn (also available as Intal HFA) Nedocromil For symptom prevention or as preventive treatment prior to allergen exposure or exercise Potential adverse effects None ( Nedocromil tastes bad ) Therapeutic issues Must be taken up to 4 times a day, maximum benefit after 4-6 weeks 7/10/2012 125 Amr Badreldin Hamdy MD FCCP

Anticholinergics:

Anticholinergics Ipratromium Bromide Albuterol + Ipratromium Bromide For relief of acute bronchospasm , especially if albuterol alone is not effective Potential adverse effects Dry mouth, flushed skin, tachycardia Therapeutic issues Does not reverse allergy-induced bronchospasm or block exercise-induced asthma May have additive effect to beta-agonist, slower onset 7/10/2012 126 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 127

Systemic Corticosteroids:

Systemic Corticosteroids Prednisolone Prednisone Prevents progression of moderate to severe exacerbations, reduces inflammation Potential adverse effects Short-term - increased appetite, fluid retention, mood changes, facial flushing, stomachache. Long term - growth suppression, hypertension, glucose intolerance, muscle weakness, cataracts 7/10/2012 128 Amr Badreldin Hamdy MD FCCP

Systemic Steroids cont’d:

Systemic Steroids c ont’d 2 or more bursts a year signifies poor control and need for daily controller 5 bursts/year in asthma is considered “steroid dependent’’ and caution should be used Tapering of oral steroids Not needed if less than 10-14 days of burst 7/10/2012 129 Amr Badreldin Hamdy MD FCCP

IgE Blocker Therapy:

IgE Blocker Therapy Omalizumab Dosing based on IgE levels and weight Only for ages over 12 years old Use in conjunction with other meds Must have evidence of specific allergy sensitivity Used for those with poorly controlled asthma and non-compliant with standard recommended therapy Delivered by SQ injection 7/10/2012 130 Amr Badreldin Hamdy MD FCCP

Managing Asthma in Special Situations:

Managing Asthma in Special Situations Asthma Exacerbations Exercise-induced Bronchospasm (EIB) Common Co-Morbidities Rhinitis Gastroesophageal reflux (GERD) Smoking Asthma in Pregnancy 7/10/2012 Amr Badreldin Hamdy MD FCCP 131

Managing Exacerbations:

Managing Exacerbations Defined as an acute or sub acute episode of progressively worsening shortness of breath, cough wheezing, and chest tightness – or some combination of these symptoms Primary therapies are SABAs, oral corticosteroids, oxygen Early treatment is the best management strategy Patient education Recognition of early signs of worsening Removal of contributing environmental Prompt communication 7/10/2012 Amr Badreldin Hamdy MD FCCP 132

Managing Exercise-Induced Bronchospasm:

Managing Exercise-Induced Bronchospasm EIB occurs in 90% of patients with asthma and >10% of the general population EIB often indicates poorly controlled asthma Use long-term control therapy, if appropriate Pre-treatment prior to exercise SABAs, LABAs are effective in up to 80% of patients LTRAs are effective in up to 50% of patients Encourage patients to warm up prior to exercise and consider wearing a mask or scarf in cold weather 7/10/2012 Amr Badreldin Hamdy MD FCCP 133

Treating the Upper Airways Can Improve Asthma Symptoms:

Treating the Upper Airways Can Improve Asthma Symptoms Avoidance/environmental control is a key treatment for both diseases Intranasal corticosteroids reduce both asthma and allergic rhinitis symptoms in patients with mild asthma Treatment with an antihistamine alone or in combination with a decongestant may reduce asthma and allergic rhinitis symptoms Cysteinyl leukotrines are inflammatory mediators in both the upper and lower mediators Leukotriene modifiers treat symptoms or asthma and allergic rhinitis Immunotherapy may reduce development of asthma in patients with seasonal rhinoconjunctivitis 7/10/2012 Amr Badreldin Hamdy MD FCCP 134

Asthma During Pregnancy:

Asthma During Pregnancy Cohort study followed 140,299 pregnancies in Tennessee Medicaid program from 1995-2003 23% of white women and 40% black women had a hospitalization or ED visit during pregnancy Black women were 1.6 (95% Cl 1.5-1.7) times more likely than white women to receive care for an exacerbation 77% of women did not use asthma control medication Dose response trend (P<0.001) between lower birth weight and increasing use of oral corticosteroids Asthma prescriptions may not be prescribed or refilled during pregnancy 7/10/2012 Amr Badreldin Hamdy MD FCCP 135

National Guidelines for Monitoring and Treating Asthma During Pregnancy:

National Guidelines for Monitoring and Treating Asthma During Pregnancy Monthly evaluation of asthma history and pulmonary function Albuterol is preferred SABA ICSs are preferred controller treatment Budesonide has most established safety profile Cromolyn , LTRAs, and LABAs may be alternatives but have lower efficacy ( cromolyn ) or less safety data available (LTRAs, LABAs) Comorbid allergic rhinitis can be managed with intranasal corticosteroids, LTRAs, loratadine , or cetirizine 7/10/2012 Amr Badreldin Hamdy MD FCCP 136

CAUSES OF NONRESPONSIVE ASTHMA:

CAUSES OF NONRESPONSIVE ASTHMA 7/10/2012 Amr Badreldin Hamdy MD FCCP 137

1. Wrong diagnosis :

1. W rong diagnosis COPD Bronchiectasis, Cystic fibrosis, Inhaled FB Recurrent aspiration. Obliterative bronchitis. Tumors involving the central airway. Tracheobronchomalacia . Vocal cord dysfunction . 7/10/2012 Amr Badreldin Hamdy MD FCCP 138

2. Poor Adherence To Therapy:

2. Poor Adherence To Therapy Patient related. Drug related. 7/10/2012 Amr Badreldin Hamdy MD FCCP 139

3. Unidentified Exacerbation Factors:

3. Unidentified Exacerbation Factors Unidentified allergies Occupational exposure GERD Systemic diseases ( thyrotoxicosis , carcinoid syndrome, Churg -Strauss Syndrome) Drugs (Beta-blockers, ACE-inhibitors) Rhinitis/sinusitis/sleep apnea Psychological factors 7/10/2012 Amr Badreldin Hamdy MD FCCP 140

4. Unstable Asthma:

4. Unstable Asthma Nocturnal asthma Pre-menstrual asthma Brittle asthma 7/10/2012 Amr Badreldin Hamdy MD FCCP 141

5. Corticosteroid Dependant/Resistant Asthma.:

5. Corticosteroid Dependant/Resistant Asthma . 7/10/2012 Amr Badreldin Hamdy MD FCCP 142

PowerPoint Presentation:

7/10/2012 AMR BADRELDIN HAMDY MD 143 Characteristics of patients at risk for Acute Asthma exacerbations Frequent emergency department visits or hospitalizations for acute asthma within 12 months Previous life-threatening exacerbations or ICU admission for asthma Excessive reliance on inhaled bronchodilator medications Patient denial of asthma diagnosis or symptoms Poor adherence to preventive strategies or controller medications Immediate hypersensitivity to foods especially nuts Asthma triggered by aspirin or other NSAIDs Poor access to health services

Causes of Near-fatal BA:

Causes of Near-fatal BA High medication use. Overuse of inhaled beta2 agonists. A history of recurrent hospitalizations. Previous occurrences of life-threatening attacks. Marked fluctuations in morning and evening PEFR measurements. 7/10/2012 Amr Badreldin Hamdy MD FCCP 144

Thermoplasty:

Thermoplasty BT is a bronchoscopic procedure to reduce the mass of airway smooth muscle and attenuate bronchoconstriction . BT uses radiofrequency energy . Once the FOB is situated in the desired airway a catheter is inserted through the FOB. 7/10/2012 Amr Badreldin Hamdy MD FCCP 145

Thermoplasty- cont’d:

Thermoplasty - cont’d The tip of the catheter is inflated until it touches the sides of the airway wall . 7/10/2012 Amr Badreldin Hamdy MD FCCP 146

Thermoplasty-cont’d:

Thermoplasty -cont’d Radiofrequency energy is then sent through the catheter, heating the smooth muscle walls of the airway to approximately 149 F. This temperature is sufficient to thin the smooth airway wall muscle without scarring or damaging them . 7/10/2012 Amr Badreldin Hamdy MD FCCP 147

Thermoplasty-cont’d:

Thermoplasty -cont’d Because BT thins the muscle walls, they cannot narrow as much when irritants trigger asthma attacks. FDA has approved BT for select patients with severe and persistent asthma who have failed maximal medical management in 2010. 7/10/2012 Amr Badreldin Hamdy MD FCCP 148

Thermoplasty-cont’d:

Thermoplasty -cont’d Physicians treat small to medium sized airways The procedure is completed in 3 treatment sessions, each lasting less than one hour, and spaced apart by about three weeks. 7/10/2012 Amr Badreldin Hamdy MD FCCP 149

Thermoplasty-cont’d:

Thermoplasty -cont’d Results include : Decrease in asthma attacks. Increase in days with no asthma symptoms. Improvement in QOL. Reduction in using medication. Improvement in asthma control . 7/10/2012 Amr Badreldin Hamdy MD FCCP 150

PowerPoint Presentation:

7/10/2012 AMR BADRELDIN HAMDY MD 151

Specific allergen immunotherapy:

Specific allergen immunotherapy One of the main differences between specific immunotherapy and symptomatic therapy is that the beneficial of SIT can be observed even years after discontinuation of treatment. In addition, SIT may prevent the occurrence of new sensitization. SIT is able to prevent the extension of upper airway disease to the lower airway. 7/10/2012 152 Amr Badreldin Hamdy MD

Specific Immunotherapy :

Specific Immunotherapy Reduction in specific IgE antibodies. Induction of blocking IgG antibodies. Alteration of T-cell cytokine production (increase in T helper 9 (Th1) cytokines). Induction of specific T-cell specific T-cell tolerance (T-cell anergy , regulatory T cells). 7/10/2012 Amr Badreldin Hamdy MD 153

SIT Pre-requirements:

SIT Pre-requirements A small number of sensitizations. Administration of adequate doses of standardized allergens. 7/10/2012 Amr Badreldin Hamdy MD 154

PowerPoint Presentation:

7/10/2012 AMR BADRELDIN HAMDY MD 155

Remember:

Remember 7/10/2012 Amr Badreldin Hamdy MD FCCP 156

Diagnosing Asthma:

Diagnosing Asthma What to look for: Episodic symptoms of airflow obstruction and BHR Airflow obstruction is at least partially reversible Alternative diagnoses are excluded How to Assess: Detailed medical history Physical examination (focus on upper respiratory tract, chest, skin) Spirometer to demonstrate obstruction and assess reversibility (>4 years of age Additional studies as necessary 7/10/2012 Amr Badreldin Hamdy MD FCCP 157

PowerPoint Presentation:

7/10/2012 158 Amr Badreldin Hamdy MD FCCP

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 159 Masqueraders of Asthma in Children Upper airway noise/congestion Cystic fibrosis (CF) Gastroesophageal Reflux disease (GERD) Bronchopulmonary Dysplasia (BPD) Foreign body aspiration Immunodeficiency (ID) Vocal cord dysfunction

PowerPoint Presentation:

7/10/2012 160 Amr Badreldin Hamdy MD FCCP

Drugs That Induce Asthma:

Drugs That Induce Asthma Beta-blockers (including eye drops) Aspirin and NSAID Inhaled asthma drugs Nebulizer solutions , hypotonic or with preservatives Angiotensin converting enzyme inhibitors 7/10/2012 Amr Badreldin Hamdy MD FCCP 161

Things to Avoid:

Things to Avoid Known allergens Active and passive smoking Areas of high pollution (particularly avoid exercising at times of high air pollution). Beta-blockers Aspirin and NSAID Obesity 7/10/2012 AMR BADRELDIN HAMDY MD 162

PowerPoint Presentation:

7/10/2012 Amr Badreldin Hamdy MD FCCP 163

References:

References 1. Gershwin ME and Albertson TE: Bronchial Asthma. A guide For Practical Understanding And Treatment. 5 th edit. Humana Press (2006). 2. Asthma . Clinics in Chest Medicine, 27 (2006). 3. Navarra T: The Encyclopedia of Asthma and Respiratory Disorders. Facts on File, Inc. (2003). 7/10/2012 AMR BADRELDIN HAMDY MD 164

References Cont’d:

References Cont’d 4. Busse WW and Lemanke JRF : Asthma Prevention. Taylor & Francis Group. (2005). 5. Rees J and Kanabar D: ABC of Asthma. BMJ Books. Blackwell Publishing. 5 th edit., (2006). 6. Barnes PJ, Rodger IW and Thomson NC : Asthma. Basic Mechanisms and Clinical Management. 3 rd edit, Academic Press (1998). 7/10/2012 AMR BADRELDIN HAMDY MD 165

References-cont’d:

References-cont’d 7. Asthma and Respiratory Disorders . Facts on File, Inc. (2003). 8. ABC of Asthma . BMJ Books. Blackwell Publ. (2000). 9. Asthma and COPD . Eksevier Ltd. (2009). 10. Asthma. A Clinician’s Guide . Jones&Bartlett Learning (2011). 7/10/2012 Amr Badreldin Hamdy MD FCCP 166

THANK YOU:

THANK YOU 7/10/2012 Amr Badreldin Hamdy MD FCCP 167