CHRONIC ILLNESS

Asthma, COAD, Epilepsy and Parkinson’s disease

Asthma

Definition Characterised by wide variations over short

periods of time in resistance to airflow in intrapulmonary airways.

Cough or wheeze associated with heightened airway responsiveness to inhaled histamine.

Inflammatory disorder of the airways, which are hyperactive in the asthmatic patient.

Pathology

Infiltration of the mucosa with inflammatory cells

Oedema of the mucosaDamaged mucosal epitheliumHypetrophy of mucus glands with

increased mucus secretionSmooth muscle constriction

Facts

Underdiagnosed and undertreated Unacceptable mortality rate of about 5 per 100000 About 1 child in 4 or 5 has asthma between the

age of 2 and 7 Most children present as a cough and are free

from it by puberty 1 adult in 10 has asthma 3 valuable home “gadgets” to help the asthmatic

are the mini peak flow meter, the large volume spacing device and the pump with nebuliser

Facts - continue

Focus of management should be on prevention

Measurement of function is vital as “objective measurement is superior to subjective measurement”

Doubling the radius of the airway increases the flow rate 16 times

Causes

Infections, especially colds Allergies to animal fur, feathers, grass pollens, mould Allergy to house dust, especially the dust mites Cigarette smoke, other smoke and fumes Sudden changes in weather or temperature Occupational irritants (wood dust, sprays and

chemicals) Drugs (aspirin, NSAIDs, beta-blockers) Certain foods and food additives Exercise, especially in a cold atmosphere Emotional upsets or stress

Additional points

Patients with asthma should not smokeAtopic patients should avoid exposure to

furred or feathered domestic animalsAbout 90% of children with atopic

symptoms and asthma demonstrate positive skin prick responses to dust mite extract

Clinical features

WheezingCoughingTightness in the chestBreathlessness

suspected in children with recurrent nocturnal cough and in people with intermittent dyspnoea or chest tightness, especially after exercise

Investigations

Peak expiratory flow rateSpirometry: value of <75% for

FEV1/VC ratio indicates obstructionMeasurement of PEFR or spirometry

before and after bronchodilator: >20% improvement

Inhalation challenge tests

Suboptimal asthma control

Poor compliance Inefficient use of inhaler devices Failure to prescribe preventive medications Using bronchodilators alone and repeating these drugs

without proper evaluation Patient fears

inhaled or oral corticosteroids aerosols and ozone layer overdose developing tolerance embarrassment peer group condemnation

Doctor’s reluctance to use corticosteroids recommend obtaining a mini peak flow meter recommend obtaining a compressed air-driven

nebuliser unit

Suboptimal asthma control - Continue

Home “Gadgets” Measurement of peak expiratory flow (PEF)

PEF meter objective readings establishment of a baseline of the “patient’s best” anyone older than 6 warning signs when using PEF

falling of PEFR and poor controlreadings less than 70% of normal bestmore morning dippingerratic readingsless response to bronchodilator

Large volume spacers increased airway deposition of inhalant and less

oropharyngeal deposition

Management principle

Aims of management abolish symptoms and restore normal airway function maintain best possible lung function at all times reduce morbidity control asthma wit h the use of regular anti-inflammatory

medication and relieving doses of beta2 agonist when necessary

Long-term goals achieve use of the least drugs, least doses, least side effects reduce risk of fatal attacks reduce risk of developing irreversible abnormal lung function

Definition of control of asthma no cough, wheeze or breathlessness most of the time no nocturnal waking due to asthma no limitation of normal activity no overuse of beta2 agonist no severe attacks no side effects of medication

Management principle - Continue

Management plan

Assess the severity of the asthmaAchieve best lung functionAvoid trigger factorsStay at your bestKnow your action planCheck your asthma regularly

Assessment of severity

Mild History : episodic, mild occasional symptoms with

exercise Medication : occasional use of bronchodilator Best PEFR : normal 100%, PEFR variability : 10-20%

Moderate History : symptoms most days, virtually symptomatic on

effective treatment, several known triggers apart from exercise

Medication : needed most days Best PEFR : 70-100%, PEFR variability : 20-30%

Severe History : Symptoms most days, wakes at night with

cough/wheeze, chest tightness on waking, hospital admission or emergency department attendance in past 12 months, previous life-threatening episodes

Medication : needed more than 3 times a day or high dose inhaled steroids>800-1200 mcg daily or oral steroids in past 12 months

Best PEFR : 70%, PEFR variability : 30%

Assessment of severity - Continue

Patient education

Read all about it Get to know how severe your asthma is Try to identify trigger factors Become expert at using your medication and inhalers Use your inhalers correctly and use a spacer if

necessary Know and recognise the danger signs and act promptly Have regular checks with doctor Have physiotherapy Keep fit and take regular exercise Keep to ideal weight

Work out a clear management plan and an action plan for when trouble strikes

Get urgent help when danger signs appear Learn the value of a peak expiratory flow meter Get a peak flow meter to help assess severity

and work out your best lung function Keep at your best with suitable medications Always carry your bronchodilator inhaler and

check that it is not empty

Patient education - Continue

Pharmacological treatment

Anti-inflammatory agents Inhaled : beclomethasone and budesonide 400g - 2000g BD,

aim to keep below 1600 g, available as metered dose inhaler, turbuhaler and rotacaps. Side effects are oropharyngeal candidiasis, dysphonia and bronchial irritationRinse mouth out with water and spit out after using inhaled steroids

Oral : Prednisolone, 1mg/kg/day for 1-2 weeks, can be ceased abruptly. Long-term use caused osteoporosis, glucose intolerance, adrenal suppression, thinning of skin and easy bruising

Sodium cromoglycate : available as dry capsules for inhalation, metered dose aerosols or nebuliser solution. Side effects are uncommon

Bronchodilators beta2-agonists : available as metered dose inhaler, a

dry powder and nebuliser solution, produce measurable bronchodilatation in 1-2 minutes and peak effects by 10-20 minutes. Traditional agents such as salbutamol and terbutaline are short-acting preparations. The new longer-acting agents include salmeterol and formoterol

Theophyline derivatives : complementary value but tend to be limited by side effects and efficacy

Pharmacological treatment - Continue

Treatment plan

Very mild asthma : inhaled beta2-agonist prn All other grades of severity

regular use of inhaled steroid or SCG plus inhaled beta2-agonist plus prophylactic use prior to exercise or allergen

challenge of inhaled beta2-agonist and/or SCG

If control inadequate add oral theophyline derivative or inhaled ipratropium for exacerbations oral prednisolone intermittent use

Inhalation technique Open-mouth technique

remove the cap. Shake the puffer vigorously for 1-2 seconds. Hold it upright to use

hold the mouthpiece of the puffer 4-5 cm away from mouth tilt your head back slightly with chin up. Open mouth and

keep it open slowly blow out to a comfortable level just as you start to breathe in, press the puffer firmly once,

breathe in as far as you can over 3-5 seconds close your mouth and hold your breath for about 10

seconds, then breathe out gently breathe normally for about 1 minute, then repeat

Closed-mouth technique : close your lips around the mouthpiece

Usual dose 1 or 2 puffs every 3-4 hours for an attack

Contact your doctor if you do not get adequate relief from your usual dose

It is quite safe to increase the dose, such as 4-6 puffs

If you are using your inhaler very often, it usually means your other asthma medication is not being used properly

Inhalation technique - Continue

Common mistakes

Holding the puffer upside down Holding the puffer too far away Pressing the puffer too early and not inhaling the

spray deeply Pressing the puffer too late and not getting

enough spray Doing it all too quickly Squeezing the puffer more than once Not breathing in deeply

Dangerous asthma

High-risk patients previous severe asthma attack previous hospital admission hospital attendance in the past 12 months long-term oral steroid treatment carelessness with taking medication night-time attacks recent emotional problems

Early warning signs symptoms persisting or getting worse despite adequate

medication increased coughing and chest tightness poor response to two inhalations benefit from inhalations not lasting two hours increasing medication requirements sleep being disturbed by coughing, wheezing or

breathlessness chest tightness on waking in the morning low peak expiratory flow readings

Dangerous asthma - Continue

Dangerous signs marked breathlessness, especially at rest sleep being greatly disturbed by asthma asthma getting worse quickly, despite medication feeling frightened difficulty in speaking, unable to say more than a few

words exhaustion drowsiness or confusion silent chest, cyanosis, chest retraction RR > 25 for adult or > 50 for children pulse rate > 120 and peak flow < 100 L/min

Dangerous asthma - Continue

Treatment continuous nebulised salbutamol parenteral beta2-agonist corticosteroids monitor PEF

Dangerous asthma - Continue

Asthma in children

Bronchodilators, inhaled or oral, are ineffective under 12 months

delivery method is a problem in childrenin the very young, a spacer with a face

mask can deliver the aerosol medicationPEF rate should be measured in all

asthmatic children older than 6 years

Prophylaxis in children

Sodium cromoglycate by inhalation is the prophylactic drug of choice in childhood chronic asthma of mild to moderate severity

A symptomatic response occurs in about 1-2 weeks

No clinical response to SCG, use inhaled corticosteroids, but risks versus benefits must always be considered, e.g. growth suppression and adrenal suppression

When to refer

Doubtful about the diagnosisFor problematic childrenFor advice on management when

asthmatic control has failed or is difficult to achieve

Practice tips Reassure the patient that 6-10 inhaled doses of a beta2-agonist is

safe and appropriate for a severe attack of asthma Important to achieve a balance between undertreatment and

overtreatment Beware of patients, especially children, manipulating their peak flow Get patients to rinse out their mouth with water and spit it out after

inhaling corticosteroids Patients who are sensitive to aspirin/salicylates need to be reminded

that salicylates are present in common cold cure preparations Possible side effects of inhaled drugs can be reduced by always

using a spacer with the inhaler, using the medication qid rather than bd, rinsing the mouth, gargling and spitting out after use, and using corticosteroid sparing medications

COAD

Chronic bronchitis productive cough on most days for at least 3 months of

the year for at least 2 consecutive years in the absence of any other respiratory disease that could be responsible for such excessive sputum production

Emphysema permanent dilatation and destruction of lung tissue

distal to the terminal bronchioles

Chronic airflow limitation physiological process measured as impairment of forced

expiratory flow and is the major cause of dyspnoea in these patients

Causes

Cigarette smokingAir pollutionAirway infectionFamilial factorsAlpha1 antitrypsin deficiency

Clinical features

Symptoms onset in 5th or 6th decade excessive cough sputum dyspnoea wheeze susceptibility to colds

Signs tachypnoea reduced chest expansion hyperinflated lungs hyper-resonant percussion diminished breath sounds pink puffer blue bloater signs of respiratory failure signs of cor pulmonale

Clinical features - Continue

InvestigationsCXR can be normalPulmonary function tests

PEFR FEV1/FVC reduced Gas transfer coefficient of CO is low if significant

emphysema

Blood gases may be normal Pa CO2 increased, PaO2 decreased

ECG cor pulmonaleHb and PCV raised

Management

Advice to patient stop smoking avoid places with polluted air and other irritants go for walks in clean, fresh air warm dry climate is preferable get adequate rest avoid contact with people with colds and flu

Physiotherapy chest physiotherapy, breathing exercises and aerobic

physical exercise program

Management - Continue

Drug therapy bronchodilators antibiotics : prompt use of antibiotics for acute

episodes of infection (sputum turn yellow or green)

sputum for C/ST and micro annual influenza vaccine home oxygen therapy

Community Care Support patients in the adaptation of recommended therapeutic

measure to their individual housing and social situation Support patient and their family in the maintenance and

trouble-shooting of technique device Involve and train caregiver in supportive measure to promote

stabilisation at home and strengthen social contact Reinforce patient adherence to therapeutic regime and

intervention Intervene patient during episodes of acute exacerbations of

COAD and refer them to other service providers by appropriate and tightly triaging

Maintain and further develop patients’ skill and functional improvement gained during the rehabilitation process

Patient Selection

Newly diagnosed and recently hospitalised patient with impairment/disability not suitable for outpatient rehabilitation programmes after discharge

Patient discharged with new respiratory equipment Patient with recurrent exacerbations and

hospitalisations despite having having received rehabilitation

Forgetful patients with poor adherence to treatment End-stage patients who want to stay at home

Epilepsy

Tendency to recurrence of seizureA person should not be labelled as epileptic

until at least 2 attacks have occurredBoth sex equally affectedRuns in some familyAn underlying organic lesion becomes more

common in epilepsy presented for the first time in patient over 25 and thus more detailed investigations is required

Types of epilepsy

Generalised seizure affects both cerebral hemispheres simultaneously from the outset and may be primary or secondary tonic clonic seizure : with musicle jerking tonic seizure : stiffness only clonic seizure : jerks only atonic seizure : loss of tone, and drops absence seizure myoclonic seizure : bilateral discrete muscle jerks and

may LOC

Partial seizures epileptic discharge begins in a localised focus of the brain and then spreads out from this focus simple partial seizures : consciousness is

retained complex partial seizures : consciousness is

clouded both can evolve into a bilateral tonic clonic

seizure

Types of epilepsy - Continue

Investigations

Standard minimum investigations : Ca, fasting glucose, EEG and syphilis serology

Chest and skull X-ray Brain scan Video EEG MRI CT

Approaches

Accurate diagnosis of seizure type Investigate and treat underlying brain disease Decision has to be made about whether drug therapy

is appropriate Choice of drug depends on the seizure type, age, sex

and on efficacy in relation to toxicity Treatment should be initiated with one drug and

pushed until it controls the events or causes side effects

If a maximum tolerated dosage of this single drug fails to control, replace it with an alternative agent

Approaches - Continue

Add the second drug and obtain a therapeutic effect before removing the first drug

Review the need for AED every 12 months. Consider drug withdrawal if free of seizures for several years

Special attention to the adverse psychological and social effects. Emotional and social support is important. Epilepsy support groups

Drug therapy

Select the most effective recommended drug for a specific seizure type

Young women prefer carbamazepine Each drug has specific adverse effects Twice daily dosage is usually practical Phenytoin should be increased in small

increments Phenytoin or carbamazepine will bring about

control in at least 80% of patients with tonic clonic seizures

Selection of AED

Type of seizure First-line therapy Second-line therapy

Tonic/clonic Sodium valproateIn young women usecarbamazepine

Phenytoin orPhenobarbitone

Absence Sodium valproate Ethosuximide orClonazepam

Myoclonic Sodium valproate Clonazepam

Simple partial Carbamazepine Phenytoin or Sodiumvalproate

Complex partial Carbamazepine Sodium valproate orClonazepam orPhenytoin

Adverse drug reactions

Nausea, dizziness, ataxia, visual disturbance or excessive tiredness/fatigue indicate excessive dosage of carbamazepine or phenytoin

Skin rash Gingival hyperplasia Hirsutism Sodium valproate has rare but potentially serious

liver toxicity and dysmorphogenic effects on foetus LFTs should be performed every 2 months for 6

months after starting sodium valproate

Patient education

Most patients can achieve complete control of seizures Most people lead a normal life Good dental care if taking phenytoin A seizure in itself will not cause death or brain damage

unless in a risk situation such as swimming Patients cannot swallow their tongue during a seizure Take special care with open fires Encourage patients to cease intake of alcohol Adequate sleep

Patient education - Continue

Driving applicants for learner’s licence need to be seizure-free for

two years, with an annual medical review for five years following receipt of the licence

Employment if liable to seizures they should not work close to heavy

machinery, in dangerous surroundings, at heights or near deep water. Careers are not available in some services, such as police, military, aviation or public transport

Sport and leisure activities avoid dangerous sports such as scuba diving, hang-gliding,

parachuting, rock climbing, car racing and swimming alone

Avoid trigger factors fatigue lack of sleep physical exhaustion stress excess alcohol prolonged flashing lights

Pregnancy successful for more than 90% slightly increased risk of prematurity, low birth weight,

mortality, defects and intervention fall in AED level phenytoin (cleft lip and palate and CHD), carbamazepine

(spina bifida), all AED expressed in breast milk

Patient education - Continue

Pitfalls in management

Misdiagnosis not all seizures are generalised tonic clonic in type most common misdiagnosed is complex partial seizures

or the variation of generalised tonic clonic seizures the diagnosis is based on history rather than EEG misdiagnosing behavioural disorders (pseudoseizures)

Overtreatment polypharmacy prolonged treatment drug interactions, especially OCP

When to refer

uncertainty of diagnosis at onset of seizure disorder to help obtain a precise

diagnosis when the patient is unwell, irrespective of

laboratory investigation when a woman is considering pregnancy or has

become pregnant to obtain therapeutic guidance assessment of the prospects for withdrawing

treatment seizures are not controlled by apparent suitable

therapy

Practice tips

EEG has considerable limitations in diagnosis < 50%

look for neurofibromatosis interactions between AED and OCP, erythromycin

and carbamazepine aim to achieve monotherapy toxic reaction can occur with phenytoin and

carbamazepine should not drive while medication is being

adjusted

Parkinson’s disease

Parkinson’s disease is the most common and disabling chronic neurological disorder

1% of adult >65 year of agemean age of onset is between 58 and 62 incidence rises sharply over 70 years of ageclassic triad : tremor, rigidity, bradykinesiaalways consider drug-induced Parkinsonism

(phenothiazines, butyrophenones and reserpine)

Physical signs

Power, reflexes and sensation usually normal

loss of dexterity of rapid alternating movements and absence of arm swing

increased tone with distraction frontal lobe signs such as grasp and

glabellar tapsno laboratory test for Parkinson’shypothyroidism and depression also cause

slowness of movement

Principles of management

appropriate explanation and educationexplain that Parkinson’s disease is slowly

progressive, is improved but not cured by treatment

support systemswalking sticks to prevent falls and

constant care is required

Pharmacological management

commenced as soon as symptoms interfere with working capacity or the patient’s enjoyment of life

levodopa in combination with a decarboxylase inhibitor in a 4:1 ratio

Bromocriptine can be used especially with the levodopa “on-off” phenomenon

selegiline promises to be an effective first-line drug

Treatment strategy

Mild (minimal disability) levodopa (low dose) or selegiline

Moderate (independent but disabled) levodopa add if necessary - bromocriptine or selegiline

Severe (disabled, dependant on others) levodopa maximum tolerated dose + bromocriptine or

selegiline consider antidepressants

Long-term problems

After 3-5 years of levodopa treatment side effects may appear in about 1/2 of patients involuntary movements (use lower dose + bromocriptine) end of dose failure (reduce duration of effect to 2-3 hours

only) “on-off” phenomenon (sudden inability to move with

recovery in 30-90 minutes)

Contraindicated drugs phenothiazines butyrophenones MAOI

Main side effects

Nausea and vomiting involuntary dyskinetic movements psychiatric disturbances on-off phenomena end of dose failure dry mouth nausea dizziness, fatigue severe psychiatric disturbances are more common

with bromocriptine

Practice tips levodopa is the gold standard longer-acting levodopa may reduce the “end of dose”

failure ensure that a distinction is made between drug-induced

involuntary movements and tremor of Parkinson’s disease

keep the dose of levodopa as low as possible to avoid drug-induced involuntary movements

in elderly fractured hip always consider Parkinson’s disease

balance of psychosis and Parkinson’s disease don’t fail to attend to the need of the family

The End

Thank you!!!

Reference

General Practice John Murtagh The Hong Kong Practitioner

Vol. 23 no. 2 “Food induced asthma attacks in children” Vol. 23 no. 6 “Avoiding pitfalls in the management of

epilepsy”

The latest COPD guideline in http://ha.home/visitor