In modern years respiratory disease like Asthma and Chronic Obstructive Pulmonary Disease were ranked as the top killer disease in urban India. Despite advances in understanding of diseases and availability of improved medication and information on treatment, the morbidity and mortality of these two diseases are increasing. Mortality appears to be particularly high in urban and rural minority population. Asthma continues to place heavy burden on patient and their families as well as a health care system.1
Asthma and chronic obstructive pulmonary disease are greatly widespread chronic diseases among the elderly, characterizes by the presence of bronchial obstruction and chronic airway inflammation.2
About one in 15 people has Asthma, a chronic condition whose symptoms are attacks of wheezing, breathlessness, chest tightness and coughing. There is no cure for Asthma, but most people can control the condition and lead normal active lives.
Different things set off Asthma and COPD attackers in different people. Smoke from cigarette or a fire, air pollution, cold air, pollen, animals, house dust, molds strong smells such as perfume or bus exhausts, wood dust, exercise, industrial chemicals all can trigger Asthma attack.3
Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play role, in particular, mast cells, eosinophills, T-lymphocytes, macrophages, neutrophills and epithelial cells. In susceptible individuals, the inflammation cause recent episode of wheezing, breathlessness, chest tightness and coughing particularly at night or in the early morning. These episodes are usually associated with widespread but variable airflow obstruction, that is, often reversible either spontaneously or with treatment. The inflammation also causes an associated increase in existing bronchial hyper responsiveness to variety of stimulai.4
NORMAL MECHANISM OF LUNGS
Your lungs bring oxygen into your body and remove the carbon dioxide and other waste gases that your body doesn't need. When you breathe in (inhale), you use the muscles of your rib cage, especially the major muscle, the diaphragm. Your diaphragm tightens and flattens, allowing you to suck air into your lungs. To breathe out (exhale), your diaphragm and rib cage muscles relax. This naturally lets the air out of your lungs. To get the oxygen your body needs, you inhale air through your mouth and nose. The mucus membranes in your mouth and nose warm and moisten the air and trap particles of foreign matter (like dirt and dust). The air then passes through the throat into the trachea (windpipe). The trachea divides into the left and right bronchi. Like a branch, each bronchus divides again and again, becoming narrower and narrower. Your smallest airways end in the alveoli, the small, thin air sacs that are arranged in clusters like bunches of balloons. When you breathe in by enlarging the chest cage, the alveoli expand as air rushes in to fill the vacuum. When you breathe out, the alveoli relax and air moves out of the lungs. Tiny blood vessels surround each of the 300 million alveoli in the lungs. Oxygen moves across the walls of the air sacs, is picked up by the blood, and is carried to the rest of the body. Carbon dioxide or waste gas passes into the air sacs from the blood and is breathed out5.
DEFINITION
ASTHMA
The term Asthma coming from the Greek verb "aazein" meaning 'to pant' , to exhale with the open mouth or sharp breath.6
Asthma is a chronic inflammatory disorder of the airways in which many inflammatory cells and cellular elements play a role. The chronic inflammation is associated with airway hyper responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.7
Symptoms of an Asthma Attack 8
Early Signs:
Wheezing or whistling when breathing
Breathlessness
Tightness in the chest
Coughing
Mild and Moderate Attacks:
Coughing up mucus
Increases tightness in chest
Severe Attacks:
Inability to breath
Trouble talking
Muscles in neck tighten
Bluish or grayish color to lips and fingernails
Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD) is a disease characterized and defined by a only physiological parameter: limitation of expiratory airflow COPD has gained attention as a major public health concern and is currently the focus of extreme research because of its steadily increasing occurrence, mortality, and disease burden. COPD is one of the leading causes of disability worldwide and the only disease for which occurrence and mortality rates continue to rise. One of the more troubling aspects of COPD is that it is under-recognized by patients, under diagnosed by physicians, and arguably under treated. In addition, COPD is a largely preventable disease, and it is incumbent on the primary care provider to appreciate optimal strategies to help their patients stop smoking and take other steps to prevent disease progression.
Chronic obstructive pulmonary disease is a obstructive condition, in this the obstruction occurred in the airflow that progressive and not fully reversible.
The chronic obstructive pulmonary disease triggers with cigarette smoke, harmful chemicals and gases. The major symptoms of COPD are prolific cough and dyspnea.
In major concerned COPD seems with smokers. COPD is both preventable and treatable. Two major forms of is chronic bronchitis and emphysema Chronic bronchitis clinically defined as swelling and increased production of mucos in bronchial tree.
Emphysema defined as abnormal or permanent enlargement of air space or air sac(alveoli) accompanied by damage of their walls without obvious fibrosis.
The major obstructive pulmonary diseases are Asthma, chronic bronchitis and emphysema. Obstruction to expiratory airflow is the common element in these conditions. Airflow obstruction in Asthma is usually reversible. COPD airflow obstruction is largely fixed or irreversible9, 10.
Asthma and COPD
While Asthma and chronic obstructive pulmonary disease (COPD) are both respiratory conditions and share similar characteristics, such as coughing and wheezing, they are two distinct conditions in terms of disease onset, frequency of symptoms, reversibility of airway obstruction and pharmacologic treatment- particularly order of use and impact on outcomes. COPD also has significantly different systemic effects outside the respiratory tract, as well as significant and different co-morbid conditions. Whereas Asthma occurs at any stage in life, COPD usually starts in the 4th or 5th decade of life and progresses insidiously in its incidence, prevalence and health impact; and while Asthma patients can have near-normal lung function with proper treatment and be symptom-free between exacerbations COPD patients rarely experience a day without symptoms.11
EPIDEMIOLOGY
According to World Health Organization (WHO) estimates 298 million people suffer from Asthma, 256,000 people died of Asthma in 2005 (WHO 2004) and over 80% of Asthma deaths are reported from low and lower-middle income countries. Asthma creates a substantial burden on persons and families as it is more often under-diagnosed and under-treated. In India, an estimated that 56,000 deaths were endorsed to Asthma in 2004 and it was seen as one of the leading cause of morbidity and mortality in rustic India. Though effective screening, assessment, and management strategies for Asthma are well recognized in high income countries, these strategies have not been fully implemented in India as evidence had previously suggested that Asthma is not to be treated independently but fitted into the general spectrum of respiratory diseases.12
ETIOLOGY13
Asthma is caused by inflammation in the airway. In Asthmatic condition the surrounding muscles of airway become tighten and the lining of air passages swells due to this reason the amount of air passed through it is reduced.
So many factors triggers Asthma and COPD attack
Respiratory infection
Allergens Airborne pollens (grass, trees, weeds), house-dust mites, animal dander, cockroaches, fungal spores
Environment(Cold air, fog, ozone, sulfur dioxide, nitrogen dioxide, tobacco smoke, wood smoke)
Emotions(Anxiety, stress, laughter)
Exercise(Particularly in cold, dry climate)
Drugs/preservatives. Aspirin, NSAIDs (cyclo-oxygenase inhibitors), sulfites, benzalkonium chloride, β-blockers
Occupational stimuli Bakers (flour dust); farmers (hay mold); spice and enzyme workers
printers (Arabic gum); chemical workers (azo dyes, anthraquinone, ethylenediamine, toluene di isocyanates, polyvinyl chloride);
plastics, rubber, and wood workers (formaldehyde, western cedar, dimethylethanolamine, anhydrides)
Tobacco smoke.
TRIGGERS FOR ASTHMA AND COPD ATTACKS
Remember that someone who takes their controller pumps / medication regularly is at lower risk for these triggers causing severe Asthma and COPD. Always use your medication the way it was prescribed. Always get an action plan so that you know what to do with a severe attack. Consult your doctor if your Asthma is not completely controlled.
Infections
Colds and other viral infections are the commonest trigger for Asthma attacks. If a child is going to a play school they may have more tight chests, but colds are almost impossible to avoid. You should talk to your doctor or Asthma nurse about whether you should have the flu vaccination or the pneumococcal vaccination.
Allergies
Exposure to the following may increase your risk of developing an Asthma attack if you are sensitive to those particular allergen, when large quantities of pollen, in very small particles, are released into the air.
Emotions
Stress or even a fit of laughter can trigger Asthma symptoms, as can family situations such as depression, money problems, deaths and work-related stress.
Hormones
Some women find their Asthma can be affected around puberty, before their periods, during pregnancy and during menopause.
Medicines
Some medicines that are used to treat a variety of conditions can lead to Asthma attacks in a small number of people. These medicines include pain tablets such as aspirin and non-steroidal anti-inflammatory tablets. Other medicines that can occasionally lead to Asthma attacks include beta-blockers, used to treat heart disease and glaucoma and some cold and flu remedy.14
Other Common Triggers for Asthma and COPD
• Dust
• Smoke (both tobacco smoke and industrial smoke)
• Cleaning products like furniture polish or Dusting sprays
• Personal care products like hair spray or perfume
• Flu, colds.15
DIAGNOSIS AND MONITORING OF ASTHMA AND COPD
The diagnosis of Asthma depends more on history, physical findings, and age related factors. Recurrent episodes of coughing or wheezing are almost always due to Asthma in children and many adults. Medical history findings that increase the probability of Asthma Include:
• Episodic wheeze, chest tightness, shortness of breath, cough
• Symptoms that worsen in the presence of allergens, irritants, or exercise
• Symptoms that worsen at night, awakening the patient
• History of allergic rhinitis or atopic dermatitis
• Family history of Asthma, allergy, sinusitis, or rhinitis similarly, certain physical examination findings can help in the diagnosis of Asthma
• Sounds of wheezing during normal breathing or a prolonged phase of forced exhalation
• Increased nasal secretions, mucosal swelling, sinusitis, rhinitis, or nasal polyps
• Atopic dermatitis, eczema, or other signs of allergic dermatitides It should be noted that the absence of physical findings (i.e. a normal lung examination) does not exclude the diagnosis of Asthma.16, 17
DIAGNOSTIC TEST FOR ASTHMA AND COPD
1. Peak Flow
Peak Flow is probably the simplest test that you can use to see how well your Asthma is doing and will be an integral part of your Asthma care plan. Peak flows can easily be done at home with an inexpensive device called a peak flow meter. Peak flow measure how quickly air can be blown out of your lungs.
2.Spirometry
Spirometry is slightly more complicated than peak flow in that it is usually done in your doctor's office and measures both how much and how quickly air moves out of your lungs. It is important in both the diagnosis and management of Asthma over time.
3. Complete Pulmonary Function Testing
Your Asthma care provider may want to determine your lung volumes and diffusing capacity. This is often done if your Asthma diagnosis is unclear. The test requires you to sit inside a special box that helps determine how much air you breathe in and out.
Lung Volumes: Your Asthma care provider may order body plethysmography test to determine your lung volumes. Asthma may cause certain changes in lung volumes that will assist your Asthma care provider in diagnosing or treating your Asthma.
Diffusion Capacity: Diffusion capacity measures how well oxygen flows from the lungs into your blood. Poor diffusion indicates damage to the lung where the oxygen and blood meet in the lungs. Diffusion capacity is usually normal in Asthmatics.
4. Chest X-Ray
A chest x-ray is a test commonly performed for patients with wheezing. An Asthma care provider will usually order one to make sure there is not some other condition that may be causing your symptoms like a lung infection.
5. Bronchoprovocation Challenge Testing
When Asthma provider orders a bronchoprovocation test, patients will inhale a specific substance through a nebulizer, often methacholine or histamine. This is done to see if patients lungs become irritated, hyper responsive, and lead to the development of Asthma symptoms. The test has a high negative predictive value. This means that if the test is negative it is unlikely you have Asthma.
6. Pulse Oximetry
Pulse oximetry is a non-invasive way to measure oxygenation of blood or how well oxygen is being exchanged between the lungs and the blood. A sensor is placed on the fingertip or other thin part of the body with blood vessels close to the skin. The sensor measures changes in wavelengths of light and is able to estimate oxygenation in the blood.
7. Arterial Blood Gas (ABG)
An arterial blood gas (ABG) is an arterial blood sample used to determine how well blood is oxygenated. A marker for oxygen exchange between the lungs and the blood. Commonly, a blood sample will be obtained from one of the arteries near your wrist. This test may likely be preformed during an acute asthma exacerbation and is more reliable than pulse oximetry.
8. Allergic testing
The relationship between allergies and Asthma has been known for a long time. Allergens you normally breathe in can increase the inflammatory reaction and hyper responsiveness in your lungs. However, your doctor cannot reliably determine if a particular allergen is responsible for your symptoms on clinical grounds alone. Because of this, your Asthma care provider may recommend allergy testing. Not all Asthmatics are tested. But if you have persistent asthma, your asthma care provider will probably recommend testing.18
MANAGEMENT OF ASTHMA AND COPD
The medications used in the treatment of asthma is categorized in two groups
Quick relief groups of medication
Long term control agents
In this quick relief agents include short acting inhaled beta2 agonist (salbutamol, terbutalin) anticholinegic agents (ipratropium bromide,tio tropium bromide) Long term controls agents which include inhaled systemic corticosteroids (budesenoide, bedomethasone), cromones (nedochromil and disodium chromoglycate) long acting beta2 agonist (salmetrol, formetrol) and antileuketrine agents (zafirleukast, monteleukast).19
INHALATION THERAPY
A different study shows that inhalation therapy is widely acceptable and more convenient in Asthma and COPD patients. Inhalation therapy is most effective, safe and cost effective of all therapy. In this therapy where the medicines are not taken as tablets or liquid as orally, but is breathed in, or inhaled. So the drug molecule directly reached in the site of action.
Advantages of inhalation therapy
Target delivery of medication
Unlike in other medication taken orally, where the absorption happens from the stomach to the blood stream and then to the target area, where the action is required. In case of inhalation the medication is directly delivered to the target area of action itself.
Quicker action
Because the delivery of the medication happens directly to the target area for action, the action and relief is much faster than the oral way of administration of the tablets.
Smaller dose of medication
When compared to the other oral form of medications like tablets, capsules and syrups, the amount of medication used in inhalation therapy is very small.
Safer
Because the dosage of medication taken is very small compare to the other form of administration of medications, the side effects are much lesser or nearly negligible, especially if the patient is on a steroidal therapy.
Inhalation Devices
Inhaled therapy is effective only when the inhaled drug particles reach the lungs and can deliver their effects there. Only very small particles, a few micrometers wide, can penetrate deeply into the lungs through the respiratory tract. This medication inhalation is done with the help of inhaler devices. An essential feature of these devices is that they release of the drug into fine, breathable particles. The inhaler device generates an aerosol which can immediately be inhaled.
Different aerosol production systems are mainly in use:
Dry Powder Inhalers (DPIs) , Pressurised Metered Dose Inhalers (MDIs) and jet and ultrasonic nebuliser.
DRY POWDER INHALERS(DPIs)
In dry powder inhalers, different techniques provide the active constituent without use of a propellant gas. Inhalation is normally simple a co-ordinate release of the active ingredient, and breath intake is not required in breathe activated DPIs. Some devices on the market differ considerably in technology and handling, as well as in their advantages and disadvantages.
STEPS
Remove the protection cap from the inhaler.
Hold the inhaler upright or level and open the inhaler by turning the mouthpiece.
Take a rotacap capsule from its container and insert the rotacap transparent end
first in to the capsule chamber.
Close the inhaler by turning the mouthpiece.
Holding the inhaler upright, push the buttons between thumb and index finger
using a slight pressure.
Breath out (not through the inhaler) gently as much as comfortable.
Put mouthpiece between lips and seal lips tightly around it.
Inhale forcefully, steadily and deeply through the inhaler.
Remove the inhaler and hold breath (5-10 seconds) following it breathe slowly.
Rinse the mouth with water and replaces the dust cap.
METERED DOSE INHALERS (MDIs)
Metered dose inhalers (MDIs) are pressurized, hand-held devices that use propellants to deliver doses of medication to the lungs of a patient. These delivery devices are critically important to public health and are used to administer various active ingredients for a range of medical conditions. MDIs play a particularly significant role in the treatment of Asthma and chronic obstructive pulmonary disease (COPD).
STEPS
Remove the protection cap from the inhaler.
Shake the inhalers for few seconds
Hold the canister up right or level
Tilt your head back and breath out slowly and completely
Put mouthpiece between lips and seal lips tightly around it.
Take a slow deep breath at the same time as pressing the canister down
Remove the inhaler from mouth
Hold the breath (5 to 10 seconds) and breath out slowly
Repeat , but wait about one minute before inhaling next puff
Rinse the mouth with water and replace the dust cap
JET AND ULTRASONIC NEBULISER
Using electrical nebuliser products allow inhalable aerosols to be released from liquid medications. The nebulisation takes place using compressed air, generated by a compressor Nebulizers appropriate for children.20,21
ROLE OF CLINICAL PHARMACIST IN ASTHMA AND COPD MANAGEMENT
A clinical pharmacist whose primary job is interacts with patients, health care providers to make the specific therapeutic recommendations. Also monitor the patient response to drug therapy and provide medicinal information. Clinical pharmacist works primarily in hospital and provides patient oriented services. Clinical pharmacist requires good communication skill, sound knowledge regarding therapeutics, good understanding of disease process and knowledge of pharmaceutical devices. Pharmacokinetic dosing and monitoring is a extraordinary skill and service provided by clinical pharmacists. Clinical pharmacists are frequently active members of the medical team and participate in ward rounds to contribute therapeutic discussions.
The seven-stars of clinical pharmacist: The seven stars of pharmacist introduced by world health organization (WHO), in its policy statement on Good Pharmacy education Practice to cover these roles: caregiver, decision-maker, communicator, manager, life-long learner, teacher and leader.
Caregiver
Pharmacists provide caring services. They must view their practice as integrated and continuous with those of the health care system and other health professionals. Services must be of the highest quality.
Decision-maker
The appropriate, efficacious, safe and cost-effective use of resources (e.g., personnel, medicines, chemicals, equipment, procedures, practices) should be the foundation of the pharmacist at work. At the local and national levels, pharmacists play a role in setting medicines policy. Achieving this goal requires the ability to evaluate, synthesize data and information and decide upon the most appropriate course of action.
Communicator
The pharmacist is in an ideal position to provide a link between prescriber and patient, and to communicate information on health and medicines to the public. He or she must be knowledgeable and confident while interacting with other health professionals and the public. Communication involves verbal, non-verbal, listening and writing skills.
Manager
Pharmacists must be able to manage resources (human, physical and financial) and information effectively; they must also be comfortable being managed by others, whether by an employer or the manager/leader of a health care team. More and more, information and its related technology will provide challenges as pharmacists assume greater responsibility for sharing information about medicines and related products and ensuring their quality.
Life-long-learner
It is impossible to acquire in pharmacy school all the knowledge and experience needed to pursue a life-long career as a pharmacist. The concepts, principles and commitment to life-long learning must begin while attending pharmacy school and must be supported throughout the pharmacistfs career. Pharmacists should learn how to keep their knowledge and skills up to date.
Teacher
The pharmacist has a responsibility to assist with the education and training of future generations of pharmacists and the public. Participating as a teacher not only imparts knowledge to others, it offers an opportunity for the practitioner to gain new knowledge and to fine-tune existing skills.
Leader
In multidisciplinary (e.g., team) caring situations or in areas where other health care providers are in short supply or non-existent the pharmacist is obligated to assume a leadership position in the overall welfare of the patient and the community. Leadership involves compassion and empathy as well as vision and the ability to make decisions, communicate, and manage effectively. A pharmacist whose leadership role is to be recognized must have vision and the ability to lead.22
INTERVENTION OF CLINICAL PHARMACIST IN ASTHMA AND COPD
Clinical Pharmacist can play an important role on the health care team by teaching patients with asthma or COPD about proper medication technique. Inhalation therapy is a indispensable method of therapy in asthma and COPD. In case of inhalation therapy the correct use of device is very important,. Patients using inhalation therapies need careful education, including step-by-step demonstration at the time of dispensing the medication, and observation of their technique. Clinical Pharmacist should re-evaluate a patient's performance when prescriptions are refilled or renewed. suitable therapy and patient adherence will prevent most emergency department visit and hospitalization for Asthma. Patients who have difficulty using these delivery devices may experience decreased aerosol deposition within the airways .Pharmacological activity occurs only when sufficient drug is reached at the bronchial receptors.
There are so many errors occurs during the usage of an inhaler such as Carrying out inhalation procedures, forget to shake inhalers prior use ,Position of inhaler when inhaling wrong number of single dose units. To overcome this type of medication errors patient counseling is essential. So clinical pharmacist can play very important role in Asthma and COPD treatment.
Interventions included activities such as Asthma severity and control assessment, Asthma care plan development, and education on Asthma symptom control, trigger avoidance, peak expiratory flow meter usage, proper inhaler technique, disease, and medication. Techniques used for education included consultation at regularly scheduled appointments in addition to 1 or more of the following: educational video, educational literature, Asthma diary.23
ACTION PLAN FOR PHARMACIST
Inform the patient about Asthma, COPD medications, life style modification.
Educate patient about the proper techniques for inhaling medications.
observe medication use and refill intervals to help patients
promote smoking cessation
Help patients discharged from the hospital understand their asthma management plan24.
REVIEW OF LITERATURE
2. Literature review
Hammerlein A et al .,(2011)25 conducted a study on Pharmacist-led intervention study to improve inhalation technique in Asthma and COPD patients, Inhaled therapy is the basis of treatment in patients with Asthma and chronic obstructive pulmonary disease (COPD). For effectiveness of pharmacotherapy, correct use of medication is required. The aim of this study was to survey the quality of inhalation technique inpatients and to determine the effect of a single intervention in community pharmacies by means of standardized procedures. A total of 757 patients with Asthma or COPD were randomly selected by 55 community pharmacies. At baseline, patients were interviewed and their inhalation technique was assessed with a 21-items checklist. Any error was recorded and, if necessary, patients were instructed in the proper use of their device. After 4-6 weeks, demonstration of inhalation technique was repeated in the community pharmacies and a pre-post comparison was performed. A total of 597 patients (78.9%) made at least one mistake in performing the inhalation technique at baseline. This number dropped to 214 (28.3%) from the first to the second appointment. All patients did benefit from the pharmacists' intervention regardless of their former training experiences. This study concluded that Inhalation technique of Asthma and COPD patients is poor. In daily practice, community pharmacy-based pharmacists are well suited to significantly supplement doctor-based education in inhalation technique.
Tricia M. Berry et al.,(2011)26 conducted a study on Asthma Friendly Pharmacies A Model to Improve Communication and Collaboration among Pharmacists, Patients, and Healthcare Providers Pharmacists, with expertise in optimizing drug therapy outcomes, are valuable components of the healthcare team and are becoming increasingly involved in public health efforts. Pharmacists and pharmacy technicians in diverse community pharmacy settings can implement a variety of Asthma interventions when they are brief, supported by appropriate tools, and integrated into the workflow. The Asthma Friendly Pharmacy (AFP) model addresses the challenges of providing patient-focused care in a community pharmacy setting by offering education to pharmacists and pharmacy technicians on Asthma-related pharmaceutical care services, such as identifying or resolving medication-related problems; educating patients about Asthma and medication-related concepts; improving communication and strengthening relationships between pharmacists, patients, and other healthcare providers; and establishing higher expectations for the pharmacist's role in patient care and public health efforts. This article describes the feasibility of the model in an urban community pharmacy setting and documents the interventions and communication activities promoted through the AFP model.
Masaya Takamura et al.,(2011)27 conducted a study on adherence to inhalation therapy is a crucial determinant of the success of chronic obstructive pulmonary disease (COPD) management. In practice, nonadherence to inhalation therapy is very common in COPD patients. The aim of the study is to assess the factors that contribute to adherence to inhalation therapy and examine their correlation with quality of life. In this a cross-sectional analysis of 88 COPD and Asthma patients was performed using a self-reported adherence questionnaire with responses on a 5-point Likert scale. This study concluded that 88 patients who were potential participants, 55 responded with usable information. The only significant factor associated with the overall mean adherence score was receiving repeated instruction about inhalation techniques. Of the 55 respondents, 22 were given repeated verbal instruction and or demonstrations of inhalation technique by a respiratory physician. Furthermore, patients with repeated instruction showed better quality of life scores than those who did not receive instruction.
Angkana Roy et al.,(2011)28 has compared inhaled corticosteroid (ICS) inhaler type with user technique and ICS medication adherence among adults with Asthma. They classified 270 adults into two groups by ICS device type: metered-dose inhaler (MDI) or dry powder inhaler (DPI). Inhaler technique was assessed using standardized checklists. Medication adherence was evaluated using the Medication Adherence Report Scale (MARS). Differences in inhaler technique and MARS score among patients using MDIs versus DPIs were evaluated. Univariate analysis showed no difference in technique scores between the groups, but better ICS adherence among DPI users. In multivariable analysis, DPI use remained significantly associated with higher rates of adherence but not with inhaler technique. The study concluded that type of inhaler device appears to be associated with adherence to Asthma controller medications. Prospective studies are needed to elucidate further the potential effect of the type of ICS delivery device on Asthma self-management.
Gallefoss frode et al.,(2010)29 Described the effect of patient education in patients with Asthma and Chronic Obstructive Pulmonary Disease on health-related quality of life (HRQoL) is not previously investigated using the St. George's Respiratory Questionnaire (SGRQ). We randomly allocated at our out-patient clinic 78 Asthmatics and 62 patients with COPD to either a control or an intervention group. Intervention consisted of two 2-hr group sessions and one to two individual sessions each by a trained clinical pharmacist. A self-management plan was developed. Baseline quality of life assessment showed comparable scores independent of treatment groups among Asthmatics and patients with COPD, but statistically significantly better scores for the educated Asthma group compared with the control group. This aligned with the SGRQ assessment, which revealed better symptoms, activity, impact respectively. Patient education among Asthmatics increased the FEV1 by a mean value of 6.1% compared with the control group. Education among patients with COPD did not indicate a significant increase in HRQoL as measured by the SGRQ or increased FEV1. We conclude that patient education increased HRQoL and FEV1 among Asthmatics, but not among patients with COPD.
Fatma Karapinar-Çarkit et al.,(2009)30 They examined the effect of medication reconciliation with and without patient counseling among patients at the time of hospital discharge on the number and type of interventions aimed at preventing drug-related problems. A prospective observational study in a general teaching hospital was performed. Patients discharged from the pulmonology department were included. A pharmacy team assessed the interventions with and without patient counseling on discharge medications for each patient. Two hundred sixty-two patients were included. Medication reconciliation without patient counseling was responsible for at least one intervention in 87% of patients After patient counseling, at least one intervention was performed in 97% of patients. After patient counseling, discharge prescriptions were frequently adjusted due to discrepancies in use or need of drug therapy. Most interventions led to the start of medication due to omission and dose changes due to incorrect dosages being prescribed. Patients also addressed their problems/concerns with use of the drug, which were discussed before discharge. They concluded that Significantly more interventions were identified after patient counseling. Therefore, patient information is essential in medication reconciliation.
Iman A basheti et al.,(2009)31 conducted a study to assess the effectiveness of a single educational intervention, followed by patient education training, in pharmacists retaining their inhaler technique skills. A convenience sample of 31 pharmacists attended an educational workshop and their inhaler techniques were assessed. Those randomly assigned to the active group were trained to assess and teach correct turbuhaler and Diskus inhaler techniques to patients and provided with patient education tools to use in their pharmacies during a 6-month study. Control pharmacists delivered standard care. All pharmacists were reassessed 2 years after initial training.. Thirty-one pharmacists participated in the study. At the initial assessment, few pharmacists demonstrated correct technique (Turbuhaler:13%, Diskus:6%). All pharmacists in the active group demonstrated correct technique following training. Two years later, pharmacists in the active group demonstrated significantly better inhaler technique than pharmacists in the control group for Turbuhaler and Diskus respectively. They concluded that Providing community pharmacists with effective patient education tools and encouraging their involvement in educating patients may contribute to pharmacists maintaining their competence in correct inhaler technique long-term.
Lavorini F et al.,(2008)32 described that wrong usage of inhaler devices might have a major influence on the clinical effectiveness of the delivered drug. This issue is poorly addressed in management guidelines. This article presents the results of a systematic literature review of studies evaluating incorrect use of established dry powder inhalers by patients with Asthma or chronic obstructive pulmonary disease. Overall, we found that between 4% and 94% of patients, depending on the type of inhaler and method of assessment, do not use their inhalers correctly. The most common errors made included failure to exhale before actuation, failure to breath-hold after inhalation, incorrect positioning of the inhaler, incorrect rotation sequence, and failure to execute a forceful and deep inhalation. Inefficient DPI technique may lead to insufficient drug delivery and hence to insufficient lung deposition. As many as 25% of patients have never received verbal inhaler technique instruction, and for those that do, the quality and duration of instruction is not adequate and not reinforced by follow-up checks. This study concluded that incorrect DPI technique with established DPIs is common among patients with Asthma and COPD, and suggests that poor inhalation technique has detrimental consequences for clinical efficacy. Regular assessment and reinforcement of correct inhalation technique are considered by health professionals and caregivers to be an essential component of successful Asthma management. Improvement of Asthma and COPD management could be achieved by new DPIs that are easy to use correctly and are forgiving of poor inhalation technique, thus ensuring more successful drug delivery.
Gillisen adryan et al .,(2007)33 described that non adherence in Asthma therapy cost in increasing mortality, morbidity, and it is coupled with rising treatment cost. In Asthma, adherence rates are often below 50%. Understanding of the needs and characters of Asthma patients as well as treatment barrier to fulfill with Asthma guidelines is important in developing programs to encourage adherence. This article presents information on common types of non adherence in asthma patients, the causes, and it reviews the literature on interventions to overcome these factors to maximize adherence rates. Although several interventions are effective in improving medication adherence in Asthma, only few considerably enhance adherence rates and clinical outcomes of these patients. An advance in treatment adherence is a multifaceted task, requiring Asthma self-management, teaching programs coupled with educational reinforcement, simplifying treatment planes and applications forms. Good communications skills among clinicians and patient education are also central for improving adherence
ElkhansaAbdelamid et al.,(2007)34 conducted a study on hospital pharmacy based pharmaceutical care service for Asthma and COPD patients. The study carried out in a hospital which located in Sudan. Study includes 100 patients, according to this study total number of patient categorized to intervention and control groups. The intervention group of patients was reviewed by trained pharmacist and this groups of patient received comprehensive medication counseling. While control group of patients received routine medical consultation. The outcome measure were recorded and results shows that intervention group have higher mean percentage of compliance compare to the control group of patients. This study pointed out that pharmacist have vital role in patient education on inhalation therapy.
WilliamsD et al.,(2006)35 described as Patient education is a vital tool for managing patients with acute bronchospasm arising from both Asthma and chronic obstructive pulmonary disease. Both are serious chronic diseases, and lack of patient education usually results in lack of patients' adherence to their therapies. Several surveys indicate that a tremendous disparity exists between physicians and patients with Asthma in how they perceive control of the patient's lung disease. A high proportion of physicians report that they provide patient education, and a low proportion of patients claim to have received adequate education. Management plans for both Asthma and COPD are outlined, including instructions for the use of peak-flow meters and profiles of inhalation devices. Although inhalation devices will continue to be the most common delivery systems for airway diseases that cause acute bronchospasm, their proper use can be both complex and diverse. Patient education, therefore, is essential for optimal benefit from therapy.
Roy A pleasants et al.,(2004)36 described that Inhaled β2-agonists are a usual treatment for patients with obstructive pulmonary diseases. Clinical efficacy, safety, and patient inclinations are important reasons that these agents have become normally used. In addition to vital bronco dilatory effects, β2-agonists have potentially clinically significant effects on the lungs including promotion of mucociliary clearance and effects on inflammation. Albuterol, and salmeterol are the most frequently used agents in world wide. In the acute care setting, short-acting β2-agonists are standard therapy for obstructive lung disease whereas the use of long-acting β2-agonists in this setting is less clear. possible clinical issues concerning the use of β2-agonists in the acute care setting include type of inhalational delivery method used, such as metered-dose inhaler versus nebulization , safety issues, and selection of agent. The role of the more recently available β2-agonists levalbuterol (the R-isomer of albuterol) and formoterol are evolving. Levalbuterol may have economic advantages in the emergency department setting, however, additional research is necessary to validate this examination.
Yuka Numata et al.,37 (2002) conducted a study on teaching time for metered dose inhalers in emergency settings. Now a days practitioners are more commonly used bronchodilator therapy with metered-dose inhalers (MDIs) as standard management. Such therapy requires that personnel ensure optimal use of these devices. We prospectively evaluated the time required to teach patients correct inhaler use for the emergency treatment of Asthma and COPD, and patient factors associated with duration of teaching. The study design on MDI arm within a single-center randomized clinical trial comparing bronchodilator administration by MDI with a delivery enhancement device. All subjects were treated for Asthma or COPD exacerbations at the respiratory acute-care day hospital of the Montreal Chest Institute, immediately after presentation to our emergency department. Inhaler-use education was provided according to a predetermined protocol. In this study Sixty-one patients with Asthma (median age, 46 years) and 32 patients with COPD (median age, 68.5 years) were randomized to treatment by MDI/DED. Mean FEV1 (percent predicted) was 63.5% for patients with Asthma and 39.5% for patients with COPD. Five patients could not complete MDI teaching and therefore received subsequent treatment by wet nebulization. For the 88 other patients, the median teaching time was 6.5 min. Shorter teaching-time requirements were independently associated with higher initial arterial oxygen saturation, home DED use after previous MDI instruction, and a single initial bronchodilator treatment by wet nebulisation. Most subjects expressed satisfaction with MDI/DED teaching and treatment. This study concluded that Successful MDI/DED teaching followed by self-medication is feasible in the emergency setting, based on a simple protocol. A single bronchodilator dose administered by wet nebulisation may facilitate subsequent MDI teaching.
Lim Kiser et al.,(2002)38 conducted a study on management of persistent symptoms in patients with Asthma and COPD. The major goals of Asthma therapy are to control symptoms, prevent acute attacks, and keep lung function as close to normal as possible. customize the regimen to relieve the patient's symptoms and control airway inflammation is important. If Asthma is not well controlled, an initial inhaled corticosteroid boost will treat the underlying heightened airway inflammation, and the addition of a long-acting beta2-adrenergic agonist or leukotriene receptor antagonist will rapidly control symptoms. Most patients do not require prolonged treatment with expensive combination or additive agents. Exercise-induced bronco constriction is a common source of symptoms. Treatments for scheduled and unscheduled exercises differ. Inhaled corticosteroids prevent frequent and severe Asthma exacerbations. When patients have persistent symptoms despite a pharmacological regimen, environmental factors and non pharmacological interventions must be considered before medication is increased. When an inhaled corticosteroid is being considered, issues of compliance, drug delivery device, and proper inhaler techniques are as important as issues of potency, clinical efficacy, and adverse effects. The new hydro fluoroalkane preparations offer more lung deposition and may be important in treating inflammation of the small airways in patients with Asthma.
Bakke et al.,(1999)39 conducted a study on the effect of patient education on steroid inhaler compliance and rescue medication utilization in patients with Asthma or chronic obstructive pulmonary disease (COPD) has not been previously investigated in a single study. We randomized 78 Asthmatics and 62 patients with COPD after ordinary outpatient management. Intervention consisted of two 2-h group sessions and 1 to 2 individual sessions by a trained clinical pharmacist and physiotherapist. A self-management plan was developed. We registered for 12 mo medication dispensed from pharmacies according to the Anatomical Therapeutic Chemical (ATC) classification index. Steroid inhaler compliance (SIC) was defined as (dispensed/prescribed) x 100 and being compliant as SIC > 75%. Among Asthmatics 32% and 57% were compliant with a SIC of 55% and 82% in the control and intervention groups, respectively. Patient education did not seem to change SIC in the COPD group. Uneducated patients with COPD were dispensed double the amount of short-acting inhaled beta(2)-agonists compared with the educated group . We conclude that patient education can change medication habits by reducing the amount of short-acting inhaled beta(2)-agonists being dispensed among patients with COPD. Educated Asthmatics showed improved steroid inhaler compliance compared with the uneducated patients, whereas this seemed unaffected by education in the COPD group
Verver S et al .,(1996)40 Many patients with Asthma or chronic obstructive pulmonary disease use their medication inhalers incorrectly. General practitioners, pharmacists and other health care providers do not always have the opportunity to instruct patients in correct inhaler technique. This study was Single blind, randomized intervention study in which 48 patients who had been using a dry powder inhaler for at least one month took part. Their inhaler technique was videotaped on two visits with a two-week interval between visits. The inhaler technique on the videos was subsequently scored by two experts on nine criteria. At both visits the patients completed a questionnaire about their respiratory symptoms. After the first video, 25 patients were randomly chosen to receive instruction from one of six practice assistants who had followed a one evening course about inhaler instruction, and who had been issued an instruction-set. The patients who received instruction had a significantly greater reduction in number of mistakes at the second visit. The instructed patients also reported less dyspnoea at the second visit .No effect of instruction was found on wheezing, cough and sputum production. This study concluded that inhaler technique of patients can be improved significantly by the instruction of patients by trained clinical pharmacists.
OVERVIEW
6. ROLE OF CLINICAL PHARMACIST IN ASTHMA AND COPD MANAGEMENT AN OVERVIEW
Asthma and Chronic obstructive pulmonary disease are highly prevalent chronic diseases among the elderly, characterizes by the presence of bronchial obstruction and chronic airway inflammation.
Asthma is a chronic inflammatory disorder of the airways in which many inflammatory cells and cellular elements play a role. The chronic inflammation is associated with airway hyper responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. Asthma treatment varies from one individual to other and is exact needs of each person.
Chronic obstructive pulmonary disease is a group of chronic respiratory disorders that lead to progressive tissue degeneration and obstruction in the airways and lungs that is not fully reversible. They are debilitating conditions that affect the individual's ability to work and function independently. These include; Chronic bronchitis, Asthmatic bronchitis and emphysema. COPD may coexist with Asthma. Pulmonary Function Testing (PFT) through the use of spirometry essential for the diagnosis and staging of the severity of disease.
ETIOLOGY
The exact reasons of Asthma and COPD are not known. The common trigger factors for Asthma and COPD are
Respiratory infection
Allergens
Environment
Smoking
Emotions(Anxiety, stress, laughter)
Exercise (Particularly in cold, dry climate)
Drugs eg: Aspirin, NSAIDs
Genetic factors.
PATHOGENESIS AND PATHOPHYSIOLOGY
Both Asthma and Chronic obstructive pulmonary disease are chronic inflammation diseases which occurred in the lungs.
In Asthma the major contributing factors are
Airway inflammation
Intermittent airflow obstruction
Bronchial hyper responsiveness
Airway remodeling
Airway inflammation
Airway inflammation is the crucial to increase Asthma, the mechanism of inflammation in Asthma may be acute, sub acute, or chronic, and the presence of airway edema and mucus secretion also contributes to airflow inflammation. Some of the principal cells identified in airway inflammation include mast cells, eosinophils, epithelial cells, macrophages, and activated T lymphocytes. T lymphocytes play an important role in the regulation of airway inflammation through the release of numerous cytokines. Other constituent airway cells, such as fibroblasts, endothelial cells, and epithelial cells, contribute to the chronicity of the disease.
Air flow obstruction
Airflow obstruction can be caused by a variety of changes, including acute bronco Constriction, airway edema, chronic mucous plug formation, and airway remodeling. Acute bronco constriction is the result of immunoglobulin E-dependent mediator discharge upon exposure to aeroallergens and is the primary part of the early Asthmatic response. Airway edema occurs 6-24 hours following an allergen challenge and is referred to as the late Asthmatic response. Chronic mucous plug formation consists of exudates of serum proteins and cell debris that may take weeks to resolve. Airway obstruction causes increased resistance to airflow and decreased expiratory flow rates. These changes lead to a decreased ability to expel air and may result in hyperinflation. The resulting over distention helps keep airway patency, thereby improving expiratory flow; however, it also alters pulmonary mechanics and increases the work of breathing.
Bronchial hyper responsiveness
Hyperinflation compensates for the airflow obstruction, but this compensation is limited when the tidal volume approaches the volume of the pulmonary dead space; the result is alveolar hypoventilation. Uneven changes in airflow resistance, the resulting uneven distribution of air, and alterations in circulation from increased intra-alveolar pressure due to hyperinflation all lead to ventilation-perfusion mismatch. Vasoconstriction due to alveolar hypoxia also contributes to this mismatch. Vasoconstriction is also considered an adaptive response to ventilation/perfusion mismatch.
Airway remodeling
Airway remodeling involves an activation of many of the structural cells, with consequent permanent changes in the airway that increase airflow obstruction and airway responsiveness and render the patient less responsive to therapy. These structural changes can include thickening of the sub-basement membrane, sub epithelial fibrosis, airway smooth muscle hypertrophy and hyperplasia, blood vessel proliferation and dilation, and mucous gland hyperplasia and hyper secretion. Regulation of the repair and remodeling process is not well established, but both the process of repair and its regulation are likely to be key events in explaining the persistent nature of the disease and limitations to a therapeutic response.41,42,43
COPD is characterized by chronic inflammatory changes that lead to destructive changes that and the development of chronic airflow limitation. Smoking tobacco induces an inflammatory response. Smoking shortens the transit time of neutrophils through the bone marrow, causes a leukocytosis and alters the immunoregulatory balance of T-cell subsets found in blood. Two major forms of COPD are chronic bronchitis and emphysema. Chronic bronchitis is an ongoing, serious condition. It occurs if the lining of the bronchial tubes is constantly irritated and inflamed, causing a long-term cough with mucus. Smoking is the main cause of chronic bronchitis. Emphysema is a subtype of COPD. Emphysema is a destructive disease of the lungs in which the alveoli (small sacs) that promote oxygen exchange between the air and blood streams are destroyed. Shortening of breath is the primary symptoms of emphysema.44
PHARMACOLOGICAL TREATMENT FOR ASTHMA
The treatment of Asthma is straight forward and the majority of patients are now managed by internist with effective and safe therapies. The main drugs for Asthma can be divided into bronchodilators, which give rapid relief of symptoms mainly through relaxation of airway smooth muscle, and controllers, which inhibit the underlying inflammatory process. Bronchodilators act primarily on airway smooth muscle to reverse the bronco constriction of Asthma. This gives rapid relief of symptoms but has little or no effect on the underlying inflammatory process. Thus, bronchodilators are not sufficient to control Asthma in patients with persistent symptoms. There are three classes of bronchodilator in current use: B2-adrenergic agonists, ant cholinergic, and theophylline; of these, B2-agonists are by far the most effective.
B2-Agonists
B2-Agonists activate B2-adrenergic receptors, which are widely expressed in the airways.B2-Receptors are coupled through a stimulatory G protein to adenyl cyclase, resulting in increased intracellular cyclic AMP, which relaxes smooth-muscle cells and inhibits certain inflammatory cells.
Short acting B2 agonist
Eg:-salbutamol, albutamol, bambuterol, fenoterol, isoproterenol, metaproteronol.
Long acting B2 agonist
Eg:-formeterol, salmeterol.
Mode of Action
The primary action of B2-agonists is to relax airway smooth-muscle cells of all airways, where they act as functional antagonists, reversing and preventing contraction of airway smooth-muscle cells by all known bronco constrictors. This generalized action is likely to account for their great efficacy as bronchodilators in Asthma. There are also additional non-bronchodilator effects that may be clinically useful, including inhibition of mast cell mediator release, reduction in plasma exudation, and inhibition of sensory nerve activation.
Side Effects
Side effects are not usually a problem with B2-agonists when given by inhalation. The most common side effects are muscle tremor and palpitations, which are seen more commonly in elderly patients. There is a small fall in plasma potassium due to increased uptake by skeletal muscle cells, but this effect does not usually cause a clinical problem.
Anti-Cholinergic
Muscarinic receptor antagonists, such as ipratropium bromide, prevent cholinergic nerve-induced bronco constriction and mucus secretion. They are much less effective than B2-agonists in Asthma therapy as they inhibit only the cholinergic reflex component of bronco constriction, whereas 2-agonists prevent all bronco constrictor mechanisms. Anti cholinergics are therefore only used as an additional bronchodilator in patients with Asthma that is not controlled on other inhaled medications. High doses may be given by nebulizer in treating acute severe Asthma.
E.g.:- Ipatropium bromide(atrovent) and combined ipatropium with albuterol sulfate combivent
Side effects
The most common side effect is dry mouth; in elderly patients, urinary retention and glaucoma may also be observed.
Theophylline
Theophylline was widely prescribed as an oral bronchodilator several years ago, especially as it was inexpensive. It has now fallen out of favor as side effects are common and inhaled B2-agonists are much more effective as bronchodilators. The bronchodilator effect is due to inhibition of phosphodiesterases in airway smooth-muscle cells, which increases cyclic AMP, but doses required for bronchodilation commonly cause side effects that are mediated mainly by phosphodiesterase inhibition. There is increasing evidence that theophylline at lower doses has anti-inflammatory effects, and these are likely to be mediated through different molecular mechanisms. There is evidence that theophylline activates the key nuclear enzyme histone deacetylase-2, which is a critical mechanism for switching off activated inflammatory genes.
Eg:-methyl xanthine
Side Effects
Side effects are related to plasma concentrations; measurement of plasma theophylline may be useful in determining the correct dose. The most common side effects are nausea, vomiting, and headaches-are due to phosphor diesterase inhibition.
Controller Therapies
Inhaled Corticosteroids
Inhaled Corticosteroids are by far the most effective controllers for Asthma, and their early use has Revolutionized Asthma therapy.
Mode of Action
The molecular mechanism of action of corticosteroids involves several effects on the inflammatory process. The major effect of corticosteroids is to switch off the transcription of multiple activated genes that encode inflammatory proteins, such as cytokines, chemokines, adhesion molecules, and inflammatory enzymes. An important mechanism is recruitment of histone deacetylase-2 to the inflammatory gene complex, which reverses the histone acetylation associated with increased gene transcription. Corticosteroids also activate anti-inflammatory genes, such as mitogen-activated protein (MAP) kinase phosphatase-1, and increase the expression of 2-receptors. Most of the metabolic and endocrine side effects of corticosteroids are also mediated through transcriptional activation.
Eg:- beclomethasone, budesonide
Systemic Corticosteroids
Corticosteroids are used intravenously (hydrocortisone or methyl prednisolone) for the treatment of acute severe Asthma, although several studies now show that oral corticosteroids are as effective and easier to administer. A course of oral corticosteroids (usually prednisone or prednisolone 30-45 mg od for 5-10 days) is used to treat acute exacerbations of Asthma; no tapering of the dose is needed. Approximately 1% of Asthma patients may require maintenance treatment with oral corticosteroids; the lowest dose necessary to maintaining control needs to be determined.
Eg: Dexamethasone, methylprednisolone, triamconolone, acetonid
Side effect
Truncal obesity, bruising, osteoporosis, diabetes, hypertension, gastric ulceration, proximal myopathy, depression, and cataracts may be a major problem, and steroid-sparing therapies may be considered if side effects are a significant problem.
Antileukotrienes
Cysteinyl-leukotrienes are potent bronco constrictors, cause micro vascular leakage, and increase eosinophilic inflammation through the activation of cys-LT1-receptors. These inflammatory mediators are produced predominantly by mast cells and, to a lesser extent, eosinophils in Asthma. Anti leukotrienes, such as montelukast and zafirlukast, block cys-LT1-receptors and provide modest clinical benefit in Asthma. They are less effective than ICSs in controlling Asthma and have less effect on airway inflammation, but are useful as an add-on therapy in some patients not controlled with low doses of inhaled corticosteroids (although they are less effective than LABAs). They are given orally once or twice daily and are well tolerated. Some patients show a better response than others to antileukotrienes, but this has not been convincingly linked to any genomic differences in the leukotriene pathway.
Eg:-monteleukast and zafirlukas.
Cromones
Cromolyn sodium and nedocromil sodium are Asthma controller drugs that appear to inhibit mast cell and sensory nerve activation, and are therefore effective in blocking trigger-induced Asthma, such as EIA, and allergen- and sulfur dioxide-induced symptoms. Cromones have relatively little benefit in the long-term control of Asthma due to their short duration of action (at least 4 times daily by inhalation). They are very safe, and though they were popular in the treatment of childhood Asthma, low doses of ICSs are now preferred as they are more effective and have a proven safety profile.
Eg cromolyn sodium, nedochromil sodium
Anti-IgE
Omalizumab is a blocking antibody that neutralizes circulating IgE without binding to cell-bound IgE; it thus inhibits IgE-mediated reactions. This treatment has been shown to reduce the number of exacerbations in patients with severe Asthma and may improve Asthma control. However, the treatment is very expensive and only suitable for highly selected patients who are not controlled on maximal doses of inhaler therapy and have a circulating IgE within a specified range. Patients should be given a 3-4 month trial of therapy to show objective benefit. Omalizumab is usually given as a subcutaneous injection.
Immunotherapy
Specific immunotherapy using injected extracts of pollens or house dust mite has not been very effective in controlling Asthma and may cause anaphylaxis. Side effects may be reduced by sublingual dosing. It is not recommended in most Asthma treatment guidelines because of lack of evidence of clinical efficacy.45
PHARMACOLOGICAL TREATMENT FOR COPD
Corticosteroids
Systemic corticosteroids are indicated in the treatment of acute COPD exacerbations
Eg: Dexamethasone, methylprednisolone, triamconolone.
Beta agonists
Long acting beta agonists may be used as first line bronchodilators in COPD. Short acting agents are used on an as needed basis for episodic symptoms. They relieve dyspnea due to airway obstruction and also they increase muco ciliary activity.
Eg : salmeterol, formoterol.
Theophylline
In COPD, theophylline compounds are used because they increase mucociliary clearance, stimulate the respiratory drive, enhance diaphragmatic contractility.
Eg : methyl xanthenes.
Anticholinergics
Anticholinergics may be used a first line bronchodilators or in conjuction with beta agonist in the treatment of COPD. They produce bronco dilation by competitively inhibiting cholinergic response and also they reduce sputum volume.
Eg: ipatropium bromide, tiotropium bromide, atropine, glycopyrrolate.42,43
INHALATION THERAPY
Inhalation drug therapy is widely accepted and most convenient method for the treatment of Asthma and Chronic obstructive pulmonary disease. Inh
