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Bronchial Asthma - Era of Personalized Therapy

Sep 12 | 6:00 AM

The therapy for bronchial asthma differs depending on the patient; in some cases, no medical intervention is required. New guidelines are being produced to discourage the use of blue inhalers. Let's look at how individualised and accurate asthma care and effect of this condition on other diseases.

[Music] good morning everyone uh i'm glad you all joined on this sunday morning with this date number and i'm sure many doctors will keep joining in so uh we have dr rahul sharma with us today who is a pulmonologist and critical medicine specialist practicing at yatharth hospital noida uh he will be discussing some uh personalized therapy options uh in bronchiology treatment options are so advanced right now and as he will tell you uh in his talk that one size doesn't fit everyone when it comes to uh any treatment of any treatment or any disease actually but let's uh focus on this and again some interesting insights today thank you and i think a good morning everyone and thank you very much for joining on this sunday morning and i think this is a very good platform which i was scrolling through and i see so many informative talks and so many informative information on netflix so probably this is one of the very important boom for the physician as well as clinician to look into and we have some important speakers also which i was also looking in the in the past presentations so i think we can all gain together from this platform i am dr rahul sharma i am dm in pulmonology and critical care and i am heading the department of pulmonology and critical care in yatarth hospital today i will be talking about a very very very common disease that is bronchial asthma but yes there are so many advancement and so many learning nowadays that you cannot just you know treat these patients with steroids so there was a notion 50 years back when it was started it was all steroids right steroid now it has come up into inhaled corticosteroid which which is again a very good boom in bronchial asthma because initially we used to see a lot of patient coming into the icu but the good part now is that none of them is coming into the icn thanks to the latest advancement and the precise medication that we have nowadays for management of this patient so as far as the asthma classification are concerned it is shifting here since the time this entity has come into the picture initially we thought that asthma is a disease then we realized that no it is not a disease it is a syndrome where a lot of disease are coming in they have different phases then again we come back to a single disease concept but now we have realized that it is although the same disease but the manifestations are different depending on your immune system so what we are talking about now not allergic and non-allergic asthma rather we are talking about at molecular level which is th1 and ts2 right so and on the basis of that our understanding is become better and better and we are targeting more and more such molecular levels and by which we are providing precise care of the medicine to our patient look at the burden of asthma in india 30 percent of the population in india are suffering from some kind of allergy which ultimately goes down to what we call as allergic march into asthma skin diseases and allergic rhino sinusitis 10 percent of the total world population is there in of the world population of asthma is there in india and prevalence of asthma in children is again very very high very recently in 10 days there was a study conducted in delhi ncr schools and they found out that up to 30 of these patients has some kind of asthma or spirometry confirm bronchial asthma which is going unnoticed and why it is going unnoticed because most of these symptoms we considered as a normal part and parcel of our life which is not the truth because if you keep these symptoms keep on going without any control then the people or the kids will definitely have more problem in the future so this is very very important and this shift is there in the guidelines where initially we were treating our patient on the opinion based guidelines because we have no robust data then it comes to the evidence-based guidelines and now we are focusing more on symptom-free word with no future extra submission which is called control based guidelines this graph although look slightly dysmorphic but don't consider that this is the ab problem this is actually the problem of out of proportion death despite being highest number of bronchial asthma patients are in our there in our country but the death is out of proportion still the disease is not well controlled still there are lot more death which can be prevented if you treat your asthma very well so this graph is bloated just because we are seeing that asthma is not well controlled and mortality in india because of poor control of asthma is very very high why it is so high because the perception regarding asthma in our population is very very poor so this was a very important study which was conducted in india and asia pacific region where they look into the the understanding of asthma in the patient and their control so they ask the patient that whether your asthma is well controlled or not and it has been seen that only 30 percent of the patient said that my asthma is well controlled and 60 of them said that no it is not well controlled but it is somewhat controlled and the remaining paper portion of patient believe that their asthma is not well controlled but the truth is you need to up you need to you know confirm this with some kind of objective parameter and we have fewer objective parameters by which we understand that whether our bronchial asthma is well controlled or not and these are called asthma questionnaire tests so you just ask five question i will be talking about that to your patient and see whether the asthma is well controlled or not and this is a surprising fact that when you apply this questionnaire to the same patient you ask these four five questions to your patient and find out that none of them was under control so this is probably why we have high is very very poor the perception is very very poor and this is the reason why two thirds of asthma asthmatic patients in india suffer from exacerbation in one year which is again very very high and probably not acceptable right why why why this is so because still although we are in the evidence-based guidelines still we are doing more of opinion-based guidelines we believe and we feel that yes my patient has asthma my patient has allergy and that that we are not using the tools which is basically meant for confirmation of the asthma and which is a very simple opt-based tool that is called spirometry by which you can confirm the diagnosis in almost hundred percent patients of your asthma when you look into the data only 53 percent of the patient physicians and 17 of the gps are truly using this tool to confirm the asthma in our patients and 22 percent of the asthmatic reported have a lung function test performance while 70 percent had never undertake such kind of test and in tertiary care center also we are facing the same problem when the patient is coming to us the the symptoms are so bad the lung function are so pure poor and surprisingly he he has visited multi multiple doctors but none of them is ever performed spirometry to such patient why because once you write bronchial asthma everybody believes that this is the truth but it is actually not there are n number of other differential diagnosis that can mimic asthma like this this is some of the list the symptoms are more or less same and you believe that if you clinically diagnose these patients most of them will fit into your asthma diagnosis that is why it is important that you label the diagnosis of asthma once you confirm this because it has a lot of significant impact in the patient's life still we believe that asthma is a disease which is associated with some kind of stigma in our country people are not very well accepting the inhalers despite we we have these far far advance in the management of our patient this misdiagnosis create a mistreatment to our patients if you are not diagnosing our patient well this also create mistrust and missed patients so patients just keep on jumping from one doctor to other doctor because the the diagnosis is not confirmed so the treatment will definitely not be optimized and why asthma it should not be confirmed because many times patients feel that their symptoms are well controlled they can't have asthma but this is the nature of this disease that it is a variable nature you feel good in the summer season the change of season is very very bad winter season is somewhat okay so people are always in confusion until unless you give a proof of diagnosis that you have asthma and these patients will accept the diagnosis well and then they are more willing to take treatment and control their symptoms so if you talk about asthma diagnosis the diagnosis is very very simple and straight forward in most of the patient although it is a heterogeneous disease but it is characterized by chronic airway inflammation which is defined by four symptoms intermittent shortness of breath chest tightness or what you call chest congestion wheezing which is a histling sound which is coming uh during the time of attack of asthma and cough which is again intermittent so none of these symptoms are persistent to make the diagnosis of asthma so that's why you need spirometry to confirm the diagnosis of asthma so if your patient has these symptoms which are frequently occurring to your patient you do a spirometry you confirm the diagnosis of airflow limitation and then you can give a confident diagnosis of asthma to your patient and this is what i was talking about symptom control again we believe that somewhat breathlessness somewhat cough somewhat chest tightness is common to us but it is never never common right if you have any kind of symptom you must apply this test this is a questionnaire based test freely available can be you know taught to your patient that he can apply these tests every four weekly and see the asthma control so by asking these four questions daytime asthma symptoms more than twice a week any night awakening due to asthma reliever needed for symptoms more than twice a week or any activity limitation due to asthma if any two answers are yes then your patient has poor control or uncontrolled asthma so all of them should be know and that is what precise target in every asthma patient that the patient should be absolutely symptom free and for that you need a personalized therapeutic operation so this was the approach to 2018 where we have two kind of uh therapy for our patient one is the controller therapy and other is the reliever therapy by saying so it means that the patient get relieved by the reliever therapy in terms of symptom control and the patient will get inhaled corticosteroid for the preferred controller which will control the symptoms over a long period of time but the scenario has changed now now the goal of the treatment is that you should have symptom free at present and you should never have any future exacerbation that is what the goal of the treatment nowadays are and they have realized that the therapy which were using which we were using for the past 50 years that is the blue inhaler or acetylene it has been realized that even in mild asthma patient where people have mild symptoms or intermittent symptoms these patients are also at a risk of development of fatal asthma attacks and to the tune of 15 to 20 percent of these patients can be can have fatal attack if they are just using uh short acting beta to agonist or what we normally call acetylene because we have learned by that way that this was the therapy which was initially available giving quick relief but it is probably not the best therapy for the patient even if it is a mild asthma but the satisfaction is more because it gives immediate relief and uh and and we all believe that my reliever gives me control over my asthma but as you can see the number this is the true number in which they have seen that even if you have mild asthma intermittent asthma intermittent symptoms your blue inhaler is not probably the best therapy for your patient and that is why the new gina guidelines which we which was came in 2019 they get away with the scenario and they say whenever you have symptoms and you have a con confirmed diagnosis of bronchial asthma you must take lava ics as a single inhaler for the symptom control also why it is so because when you are taking a reliever with the hair like acetylene it is just improving your symptoms but not controlling the underlying disease so they say that whenever it is required for the control of symptoms always take lava ics combination which gives you immediate relief and also it is suppressing the inflammation inside the body which is also preventing the future risk of asthma exacerbation in you right and there so this is this is same thing the other approach is when your asthma is not well controlled with your low dose ics and lava then you need to see that what else can be done in such patient and these are the patients who require personalized precise medication therapy so as soon as you feel that your patient is poorly controlled partially controlled or not controlled on low-dose lava ics you start categorizing your patient that what is the best suited treatment for my patient and these patients comes under the category of moderate asthma to severe asthma which gina says that they are in step three step four and step five so how do you define step three step four and step five if you are on low dose lava is combination moderate dose of blah biases combination or high dose lab ics combination control partially controlled or not controlled but if you are on step three four five you need personalized therapy right so this is again very important that the new restriction and we we all have realized postcode that the steroids although can do good but it can do worse in you also long term use of oral corticosteroid is very very dangerous so we should try and avoid these oral corticosteroids wherever is possible and asthma is one such disease where you can completely avoid or prevent exacerbation and avoid the use of low dose or oral corticosteroid therapy that's why they have warned that if you have in step three four five you must phenotype yourself and look for the precise therapy by saying low dose how does what does it mean so when you talk about asthma two molecules which are most commonly given to the patient is buddhisonite and fluticasone so if your patient is taking bluedisonite 400 to puff bd then your patient is in high dose if you are taking fluticasone propionate to puff if the dose is more than 500 then your patient is in high dose so they have kept a very very low threshold for even for inhaled corticosteroid and if you are crossing that threshold probably you are the patient who needs personalized therapy and phenotyping and this is a sad reality in india where up to 90 of the patient has reported an average use of oral corticosteroid more than 10 times a year which is a very very high requirement all of them believe that as soon as they take steroid their symptoms are well controlled but none of them ever think about the side effect profile of these steroids or what these steroids are doing to your body when you are repeatedly taking it in the oral form nonetheless when you feel that your patient does not have well control of their asthma you need to look into the other aspect whether the patient is taking the medication appropriately whether the patient is compliant with the medication whether the technique is correct whether the drugs are actually going inside the lung is there any comorbidity like allergic nano sinusitis obesity gerd all these things needs to be controlled and whether the patient is taking any onward going exposure like most of the patients do smoke and take inhalers so it doesn't work that ways you need to avoid the allergens wherever it is possible it is probably one of the best way to control the asthma so underlying patient adherence to the therapy is always a prerequisite when you are stepping up the therapy of asthma in your patient so coming back to the severe asthma so patients who are not well controlled on moderate to high dose of lava ics and lava combination or who are taking recurrent uh oral corticosteroid these are the patients who are at the risk of death because of this asthma who are at the risk of severe side effects of inhaled corticosteroid and these are the patients who are actually utilizing the maximum resources despite being a very few number so what does it mean if you have severe asthma then you have decline in your lung function which is very very fast you have unacceptable daily symptoms or rather you will have persistent symptoms which requires more hospitalization increased medication burden and leads to increased risk of future severe exacerbation so going back into the deeper pathobiology of asthma where the the initial conventional teaching is that you you have either atopic asthma and atopic asthma that means that you have either allergic asthma and no level energy but now we have going a step backward that what is creating this atopi and known atopi so it has been realized that it is basically ts2 and th1 driven so people who have allergy they are th 2 driven or they are called ts2 high asthma and these ts2 related interleukins 5 creates inflammation with the help of eosinophils and muscles where people who have low ts2 they have predominant th1 function where the predominant symptoms are because of muscular smooth muscle hyper reactive airways or smooth muscles uh proliferation in the lung and these are the patients whom uh steroid doesn't work very very well so inhaler doesn't work very very well in these patients so you need to see and understand that which patient is the best candidate so that is why the new concept has come where you need to look beyond the accepted therapies and the single inhaler you cannot treat each and every patients of bronchial asthma so in personalized therapy where we were conventionally taught talking about allergic and non-allergic asthma now we are thinking and seeing the deeper pathobiology as ts2 and non-ts2 so ts2 are those who has some kind of allergy these are the patient whom you need a critical evaluation of their allergic profile which includes serum ige levels and we were talking about the eosinophils which is creating a critical role in the symptom of the in in symptomatology of these bronchial asthma patients so we are looking into the surrogate marker of eosinophilic inflammation in the lung with the help of fractionated exhaled nitric oxide which is a surrogate marker of eosinophilic inflammation inside the lung we are looking into the blood eusynophilic levels and you are looking into the sputum mucinophilia and the group of patients which is coming into this ts2 predominant bronchial asthma are those who has atopic asthma who has exercise induced asthma who has allergic asthma who has late onset of xenophilic asthma and people who has some kind of very late onset asthma so these are the patients who have eustinophilias related asthma and non allergic or non ts2 type r1 who have basically smooth muscle proliferation and more of constriction which is mainly related to obesities and other factors so looking into this profile is very very important why because now we have a personalized targeted therapy for each particular molecular patho biology that is happening in these patients suppose the patient has eosinophilic driven symptoms and poor control of asthma then we have ntil5 which was the molecule which is actually activating the il5 is activating the eosinophils so anti-il5 therapies are basically blocking that pathway and giving a good control over your asthma symptoms rather than just treating these patients with anti-allergy therapy the other one is ige if you have very high ig leveling which is actually uh creating uh mast cell uh degranulation leading to the symptoms of your patient then you can actually block these anti-ig these are called biological therapy in bronchial asthma or malignant is the most utilized therapy in patients whom you have high ig levels and you have more control of asthma our patient is in step three four or five so this is this antibody basically bind to the free ige levels in the blood and stop the cascade of degranulation of muscles in your body how malicious maps basically patient who has severe persistent allergic asthma high ig levels who are on high dose or moderate dose of lava ics and they have some kind of allergy allergen in their skin prick test or rust panel which is the blood-based test then these are the patient whom can be selected for malaysia map therapy and the evidence is so robust that these therapies are work work wonderfully and they have very good safety profile and literature over a period of 20 years is now available which says that it decreases the severe exacerbation rates it improves the lung function it reduces the requirement of oral corticosteroid and it decreases the rescue medication by doing so it improves the overall quality of asthma patients quality of life is the concept or the major or the target that we are looking for rather than simply giving them some partial relief and it is well tolerated and have has a very good safety profile the other biological which is in the market and now available in india also is anti-il5 so the cut-off value that has been given for anti-l5 either you have sputum eosinophilia more than three percent or your blood eosinophils more than three hundred then you consider these patients for uh anti-il5 therapies so what does it do it basically depleted the eosinophil uh by monoclonal these are monoclonal antibodies which depleted the eosinophils or it causes cell mediated cytotoxicity and decreasing the level of eosinophils which is basically the cascade and creating all the symptomatology in severe asthma patient so using anti-iron 5 in severe eosinophilic asthma has an important treatment options for patients who has high eusinophil in their blood and it is has a very good clinical safety profile it significantly reduces the risk of exacerbation requiring hospitalization it retain therapeutic efficacy across the spectrum of exacerbation severity and the baseline use of oral corticosteroid also goes down very very then so these are some of the biomarkers which i'll be talking about in my next two slides exhale nitric oxide the latest test in the market where you simply have to blow your breath and you need to see that what are the level of exhale nitric oxide which is coming inside through our breath so this exhale nitric oxide is basically the marker that you if it is high then you have eosinophilic inflammation inside your lung so if your pheno is more than 15 part per billion it is associated with eosinophilic inflammation in your body and you are probably the candidate for inhaled corticosteroid if the dose goes high then we have anti-il5 therapy for the management blood using a will count again a very very important marker and very simple test you just have to do your cbcm count the eosinophil levels in this and this also have been shown to be increased uh and shown uh poor uh lung function in the patient who has frequent extra separation induced pornosinophils what you are doing your basic numbers in your sputum although looks very very simple but it is a cumbersome test not available everywhere because you you need a special so most of the time we are going with blood using a fill level rather than sputomeroxynophils level and these blood eosinophil levels should be manually count by the pathologist rather than the machine generated report what drugs do when you give these anti il5 therapy to your patient it significantly decreases the number of using fills in your lung by doing so it is reducing the exacerbation or the asthma attacks and greater reduction is being seen if your eosinophilia is high so as low as 150 cells per microliter you can get benefit of this molecule but if your using a field counts are very high then probably the benefit is much much higher and these benefits sustained for a longer period of time so if you give this therapeutic operation for let's say one year the response persists for up to five year in such patients and this is again a very very good boom because you the the dose of oral corticosteroid which is requiring which which is required for recurrent attacks persistent symptoms to these patients goes down to 90 so so you can definitely prevent the risk of side effect of oral corticosteroid in your patients so this is again a very very important thing that not only you want to treat your patient but you want to treat your patients safely that you sh that the patient should have minimal or no side effect of the drugs or the medication that you are providing to your patient benrys map has been recently available in the market it is again work by different mechanism on il5 receptors and causes the death or the the killing of eoxinophil cells in the lung and gives all the benefit which which which will we will perceive that high use you know fill count is doing any detrimental role in our lungs so it decreases the role exacerbation rate improve the symptoms improve the quality of life uh it causes less frequent exhibition and less use of oral corticosteroids so it has shown some better response and this is what it is the exacerbation or the attack rates decrease down by 60 percent the new data is showing it up to 75 percent lung function improves asthma symptoms are better and use of oral corticosteroid is minimized with the help of this molecule how do you monitor such patient so you need to give anti-il5 treatment or homolysium treatment for minimum four months and then you see the response if you feel that your patient is responding well symptoms are less lung functions are better exacerbation are led quality of life better improvement in comorbidities are is there then you continue these therapies for up to one year and see the response in your patient so the other other group of patient which i was talking about was ts2 low patient where the inflammation is not because of and this eosinophils or mast cells and in zytromycin for a longer period of time has shown decrease in the exacerbation rate and improvement in the overall quality of life to these patients the other therapy which is now available in india is bronchial thermoplasty it is basically a nurby where as i was mentioning that in ts2 low patients the smooth muscles or the wall of the airway is increase so what we do by this that you give a therapy and decrease the muscular mass in the airway so the airways are open better and you get better response in your patients in whom energy is not the predominant symptoms these this is basically for the patient whom you find that eosinophil levels are not high uh ig levels are not high so we believe that this patient has ts2 low type of bronchial asthma and these patients if have frequent exacerbation poor quality of life is probably the best candidate for bronchial thermoplasticity which is done through the help of bronchoscopy in three settings and the response rate is very very good so this is a real-world study where a three-year follow-up in australia was being evaluated and they see that the rate of severe exacerbation emergency department visits hospitalization decrease significantly in patients whom you treat with bronchial thermoplasty so this is the the cracks of my talk where we are talking about personalized therapy in each ns each and every patient of bronchial asthma where you are giving moderate to high dose of steroids in this what we are actually doing we are categorizing these patients on the basis of ige levels sputum eosinophils bloodiosynophils their symptom levels and on the basis of this we are keeping these patient into different boxes like nonotopic atopic th2 low endotopic asthma and deciding that which is the excuse which is the best molecule for these patients to provide the maximum benefit with minimal side effects and you should always consider these non-pharmacological intervention in each and every patient of your yours whether the patient is on inhaled corticosteroid taking advanced treatment cessation of smoking do not gain weight physical activity avoidance of occupational exposure allergen pollution avoidance of medication that can precipitate your bronchial asthma doing regular breathing exercises healthy diet weight reduction vaccination now for covet along with flu and pneumococcal and dealing with emotional stress is the key for proper management of your patient which requires a comprehensive care rather than a single drug and this is not a single drying process as i said that asthma is a disease which is vaccine and veining so in every time you need to look into the response rate of your patient look into the technique look into the parameters assess your patient modify the treatment and adjust the treatment and this is an ongoing dynamic process for each and every patient of yours so the duty does not end when you diagnose your patient as asthma but the responsibility increases when you diagnose a patient with asthma because it is your duty now to give proper good control of asthma and prevent almost every extra sufficient in future for the better quality of life in your patient by seeing this i'll just summarize that what to take off uh take home from this netflix webinar that we must diagnose each and every asthma patient before starting the treatment to this patient the treatment is now symptom driven that you need to control the symptoms and prevent the future exacerbation there is no role of isolated acetylene or short acting beta to agonist in the management of symptoms of your patient even in step one where your patient has very mild symptoms or intermittent symptoms and new restriction has been given on the use of oral corticosteroid therapy so whenever if at least even once in a life in one year if you feel that your patient is taking oral corticosteroid for the symptom control of bronchial asthma your patient is a candidate for personalized therapy high dose ics lava included in step five is again a clear recommendation that you should not continue your patient on this high dose ics lava combination rather send the patient to specialist phenotype these patients and provide personalized therapy to these patients and personalized treatment should be considered for patients who are on moderate to high dose of ics lava therapy and do not ignore non-pharmacological intervention and vaccine is one of them which every one of us should take many of my patients are coming up that they have asthma they have high ige and whether they should take covert vaccination or not but let me assure you that this is the vaccination which will benefit you the max because you are at a risk of development of any kind of respiratory illness much more than the people who are not have their lung disease so this is absolutely safe vaccination is and is one of the non-pharmacological intervention by which you can prevent the the infection rate as well as exacerbation of your bronchial asthma by this i conclude my talk thank you very much for your patient listening if you have any question i'll be very very happy to answer yeah thanks a lot sir it was really amazing so we have some questions uh i'll just uh i'll stop presentation first so we'll take two questions i told dr suman has asked most essential uh lab parameter to diagnose bronchitis so the most essential parameter is not the lab parameter it is basically the symptoms of the patient and spirometry in spirometry you need to look into the obstruction as well as bronchodilator reversibility many times what happened that the patient comes in symptoms and we feel that once the symptom will be stabilized then we'll do the test but no when the symptoms are there that is the best time to confirm the bronchial asthma rather than you wait when the symptoms get resolved because it is a vaccine and many disease once the symptoms are over you might not be able to uh confirm the bronchial asthma even by spirometry lab tests are required only for those patients whom you feel that after diagnosing asthma and you have given a lava ics combination in low dose and your patient is not well controlled then you need to phenotype this patient so eosinophil count and serum ige are the two most important lab parameters that you should evaluate in each and every patients of your bronchial asthma right so uh is there any role of dc in your xenophilic estima sorry dec so dc is altogether a different uh disease it is the eosinophilic lung diseases which mimics asthma it is not asthma so if your patient has very high eosinophil levels these patients usually have infiltrates or pneumonic patches in the lung where asthma does not have any mnemonic patches in the lung and these are the patient whom you do blood tests look for this worm and if it is confirmed then you can give dec for 21 days to this patient and see the response but it is now very very rare and very very uncommon right okay so uh does omalisuma prevent progression of cops or remodeling of airways yes definitely if you talk about uh homali's map if you prevent exacerbation in your patient by doing so you are decreasing the inflammation in your patient and this is this inflammation actually causes remodeling so if you prevent the attack of asthma or symptom control in your patient by and suppress the inflammation all kind of remodeling can be prevented and homolysed map is is one such molecule in patients who have housed a smite allergy or any aero allergy and high ig you give molecule and you can prevent the remodeling in such patients right okay so there are a lot of questions about phenotyping as well so uh but can we just uh cover that in a bit oh yes yes so so this is this is the talk which is all about phenotyping basically when do you suspect that your patient needs phenotyping if your patient has moderate to high dose of ics and they are not well controlled in terms of the four questions that i have mentioned which is called asthma control test so it is available online if you feel that your patient has not well controlled in terms of symptom if he is controlled then in the past one year if he had any kind of extra sufficient then these are the patient who needs personalized or phenotyping and phenotyping is done very very easily with the help of serum ige level uh eosinophils level in your patient but before doing phenotyping or jumping on to phenotyping you need to look into the comorbidities of your patient let's say your patient has bronchitis and allergic rhinocerositis if you will not control allergic kind of sinusitis in your patient your patient will never be controlled on asthma also so it is very very important it is a step wise process whenever you feel that my patient is rolled despite being diagnosed as asthma confirm the diagnosis of asthma check for the technique whether the patient is taking drugs continuously and properly or not look for the commodities whether the comorbidities are there and well controlled and then jump to the phenotype right okay so i hope this clears everyone's doubt about phenotyping now uh there is a one question how to differentiate tropical use you know failure and new ones that my listener yes it is very very important and very very pertinent question that how to differentiate tropical eosinophilia so tropicalyosinophilia has two three disease one is your law floor syndrome other is your chronic eosinophilic diseases and the third one is worm related diseases so in chronic eusinophilic diseases you have high blood count in acute diseases generally blood doesn't have eosinophilias rather they have lung infiltrates so most of these diseases is present as pneumonia rather than bronchial asthma so if you have bronchial asthma or you have this doubt whether you have eusinophilic lung disease or bronchial asthma doing hrct if there is there are infiltrates it goes more towards eosinophilic lung disease rather than bronchial asthma okay so uh when you say that uh for bronchial asthma spirometry forms the basis of diagnosis or the initial phase also so there is one question in rural area where there is no cytometry available uh what is the option how do we go about it so although looking into the the progress that we are doing in rural areas spirometry is not a very big machine or very costly machine it can be very well set up in a single center and all these patients can be referred to that phc or csc for once diagnosis and then they again can come back and take their treatment even if you don't have this spirometry at your center a device which comes by the cost of 350 rupees called peak expiratory flow meter by the name of breathometer you can check the patient's capacity for a week and look for the variability in this also if it is more than 20 there is a very very high chance that these are the patients who are suffering from bronchitis the best monoclonal antibody for asthma which is food so all of them all of them are true none of them is for emergency these are for the patients whom you don't want to get admitted in emergency so this is basically you need to understand that this is more of you know maintenance therapy where you don't want to you don't want your patient to get sick and hospitalized and admit in icu there is no best monoclonal antibodies you need to look into the patient profile by which i i mean that you need to categorize your patient phenotype your patient and on the basis of that you decide whether your patient is fit for uh anti-ig therapy which is a malaysia map or ntil5 therapy which is bendalizumab and nepalism right um so there is one uh ambiguous question i'll just read it out or dr has asked so how much time will it take uh when we say aspirin or long time use or include one of the conditions so so so yes i i got that question so there is a term called aspirin induced asthma but most of the time it is not that the long term use of aspirin causes asthma in your patient it is a idiosyncratic reaction as soon as you take aspirin you will have symptoms so it is more of allergic or anaphylaxis it is not enough lexis person but more of idiosyncratic idiosyncratic reaction that every time you take aspirin or nce you will have more symptoms and there are aspirin challenge tests available in which you give a small dose of this and do the pfd and see there is the decrement in the lung function but once you have allergy to aspirin you cannot take it actually every time you take it you will have these symptoms okay so doctor i hope this answers uh so there is one last question i'll take now so if you have any more you can actually put and we have like some time so we can take but most of them are covered so if if there is anything just feel free to ask so there is one question patient under seroflow 125 mg past seven years uh using a fill count is high uh dust allergy is present can this patient take a covet vaccine so as you have already explained uh anyone can take but in this condition i don't know i think i think i think this this why everyone is so confused about this because one of the manufacturer initially said that if your ig levels are high then you cannot take this vaccine but nowadays it has been clear that there is no such contraindications to the people the only thing that you need to consider here is that your asthma is well controlled if your asthma is well controlled you can very well take your vaccination so uh it is the clinical outcome that we have to see uh in every condition so if it is well controlled and balanced at every stage then there is no issue with the vaccine right now because there are no any exceptions mentioned in the guidelines as well right yes just one so can you just quickly come up about uh childhood or pediatric asthma control management like in you so i think uh pediatric asthma control management is same as the adult asthma management only the devices are little difficult and it is very very difficult to give these inhaler to the pediatric population so we have jet nebulizer mass nebulizer for them people who are more than six years of age they can be treated as adult asthma only only the doses are different which can be given on the basis of their weight symptom control is again has to be seen with this people who are less than six years of age you actually need to look into their daily routine activities and their comparison with their peers whether they are able to do exercise whether they are able to do run running exercises outdoor games and they are not getting tired very very early there is a new technique for the diagnosis of asthma in these patients because what i was talking about spirometry is for adult person but when we talk about pediatric population less than eight year of age kid cannot perform spirometry so there are impulse oscillometry which is a new technique to confirm airway inflammation or obstruction in this patient has come up and is now available in india and you can do this and you can do this and confirm the diagnosis of asthma even in pediatric population okay but the overall management is same as it is same the only thing that you need to see the indication of these biological that i have talked about malice map can be given more than six year of age uh benalizumab and nepalese may have more than 12 year of age perfect so uh we have answered most of the question so uh it was really interesting and amazing the data points that you mentioned were really good sir thanks a lot uh for this session and i hope to see you again uh with some interesting topics in pulmonology and sleep medicine so yeah thanks a lot thank you thank you very much everyone for the patient listening and i i can see that the interest was so much because this is one of the disease which is very very common and most of the time ignored and by most of us but the only thing that you need to consider and targeting each and every asthma patient that there should be no symptoms and no attacks that is if you can control this then probably the best treatment has been provided to your patient thank you very much for your patience

BEING ATTENDED BY

Dr. Darius Justus & 702 others

SPEAKERS

dr. Rahul Sharma

Dr. Rahul Sharma

Senior Consultant & Head | Pulmonology, Sleep & Critical Care Medicine | Yatharth Super Specialty Hospitals, Noida

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dr. Rahul Sharma

Dr. Rahul Sharma

Senior Consultant & Head | Pulmonology, Sleep...

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